VA HEALTH CARE

Actions Needed to 

Improve 

Administration and 

Oversight of Veterans’ 

Millennium Act 

Emergency Care 

Benefit

Report to Congressional Requesters

March 2014

GAO-14-175

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-175, a report to 

congressional requesters

March 2014

VA HEALTH CARE

Actions Needed to Improve Administration and 

Oversight of Veterans’ Millennium Act Emergency 

Care Benefit

Why GAO Did This Study

VA spent an estimated $418 million on 

Millennium Act emergency care claims 

in fiscal year 2012 and projects 

spending will increase to $580 million 

by fiscal year 2015. GAO was asked to 

review VA’s administration of the 

emergency care benefit under the act. 

This report examines the extent to 

which (1) selected VA facilities 

complied with applicable requirements, 

in particular when denying claims; 

(2) VA’s oversight activities ensure that 

Millennium Act claims are not 

inappropriately denied; and 

(3) veterans understand the Act’s 

emergency care benefit and how VA 

communicates with non-VA providers 

about Millennium Act claims. 

To do this work, GAO reviewed 4 VA 

facilities out of 142 based on variations 

in Millennium Act spending levels and 

geographic location. GAO also 

reviewed VA documents—including 

128 denied Millennium Act claims from 

these four facilities—and interviewed 

officials from VA, non-VA providers, 

and veterans service organizations. 

These results cannot be generalized 

across VA but provide insights.

What GAO Recommends

GAO recommends that VA take a 

number of actions, including steps to 

ensure facilities comply with applicable 

requirements, notify veterans of 

denials, improve oversight of claims 

processing, and collect better data on 

denials and veterans’ understanding of

eligibility for Millennium Act coverage. 

VA agreed with the recommendations 

and described its plans to implement 

them. However, as described in the 

report, GAO believes that some of 

VA’s proposed actions do not fully 

address the issues identified.

What GAO Found

The Veterans Millennium Health Care and Benefits Act (Millennium Act) 

authorizes the Department of Veterans Affairs (VA) to cover emergency care for 

conditions not related to veterans’ service-connected disabilities when veterans 

who have no other health plan coverage receive care at non-VA providers. 

However, GAO identified a number of instances where VA staff who processed 

claims did not comply with applicable requirements of the Millennium Act, its 

implementing regulations, or VA policies when they denied the claims. 

Specifically, at the four VA facilities included in this review, GAO found 66 

instances of noncompliance among the 128 denied claims reviewed, which led 

some claims to be inappropriately denied. VA facilities subsequently 

reconsidered and paid 25 of these claims. GAO also found that VA facilities may 

not be notifying veterans as required that their Millennium Act claims have been 

denied. Eighty-three claims out of 128 that GAO reviewed lacked documentation 

that the veteran was notified of the denial or of his or her appeal rights. These 

findings suggest that veterans whose claims have been inappropriately denied 

may have been held financially liable for emergency care that VA should have 

covered, and they may not be aware of their rights to appeal these denials.

GAO also found that, as a result of weaknesses in VA’s oversight of Millennium 

Act claims, VA facilities are at risk for inappropriately denying such claims. For 

example, agency oversight activities do not focus on compliance with all 

applicable requirements but rather on the timeliness of claims processing. In 

addition, VA has limited assurance that deficiencies relating to Millennium Act 

claims processing identified during reviews are corrected because it only 

conducts limited follow-up with VA facilities. Moreover, VA does not collect 

adequate data for monitoring the appropriateness of Millennium Act claim 

denials. This lack of data hinders VA’s ability to track patterns as to why 

Millennium Act claims are denied and identify areas where communications with 

veterans and non-VA providers about Millennium Act emergency care benefits 

could be improved.

VA has used various methods to educate veterans about their Millennium Act 

eligibility; however, VA officials, non-VA providers, and representatives of 

veterans service organizations told GAO that veterans still lack knowledge about 

their eligibility. For example, VA officials reported that because some veterans 

were uninformed about their eligibility, these veterans may have delayed or 

avoided seeking treatment at local non-VA providers, choosing instead to go to a 

less accessible VA facility. Because VA does not require facilities to conduct 

evaluations of veterans’ understanding of Millennium Act eligibility, it lacks 

information needed to address potential gaps in veterans’ knowledge about these 

benefits. Also, the non-VA providers GAO interviewed cited communication 

challenges with VA regarding Millennium Act claims, such as not having a 

specific point of contact at VA for directing specific questions and raising 

concerns, and a lack of VA responsiveness when issues are raised. Despite VA’s 

efforts to improve communications with non-VA providers after a 2011 customer 

service survey revealed significant issues, these challenges persisted at the 

facilities GAO visited.

View GAO-14-175. For more information, 

contact Randall Williamson at (202) 512-7114 

or williamsonr@gao.gov.
Page i GAO-14-175 VA Millennium Act Emergency Care

Letter 1 

Background 6

Selected VA Facilities Did Not Consistently Comply with 

Applicable Requirements for Processing Claims and Notifying 

Veterans When Denying Millennium Act Claims 12

VA Lacks Sufficient Oversight Mechanisms and Data to Ensure 

that VA Facilities Do Not Inappropriately Deny Millennium Act 

Claims 22

Despite VA Efforts, Veterans Lack Knowledge about Millennium 

Act Eligibility, and Selected Non-VA Providers Report 

Communication Challenges with VA Regarding Millennium Act 

Claims 29

Conclusions 37

Recommendations for Executive Action 38

Agency Comments and Our Evaluation 40

Appendix I VA’s Process for Receiving Fee Basis Claims and Processing 

Millennium Act Claims 49

Appendix II Example of a Standard Veteran Denial Letter for a Claim Related 

to a Motor Vehicle Crash 50

Appendix III Comments from the Department of Veterans Affairs 51

Appendix IV GAO Contact and Staff Acknowledgments 59

Related GAO Products 60

Tables

Table 1: Site Visit Locations 4

Table 2: Types of Fee Basis Claims Processed by VA and 

Relevant Payment Authority 7

Contents
Page ii GAO-14-175 VA Millennium Act Emergency Care

Table 3: Hard Copy Millennium Act Claims Reviewed that Were 

Not Date-Stamped, at Four Selected VA Facilities 13

Table 4: Hard Copy Millennium Act Claims Reviewed with Scan 

Dates 30 Days or More after Creation Dates, at Four 

Selected VA Facilities 14

Table 5: Denied Millennium Act Claims Lacking Documentation 

that the Veteran Was Notified of Denial and Appeal 

Rights, at Four Selected VA Facilities 21

Figures

Figure 1: VA’s Process for Receiving Fee Basis Claims 8

Figure 2: VA’s Process for Determining Payment Authority and 

Verifying That Emergency Care Claims Were Routed to 

Correct VA Facility 9

Abbreviations

FBCS Fee Basis Claims System

Millennium Act Veterans Millennium Health Care and Benefits Act

VA Department of Veterans Affairs

VSSC Veterans Integrated Service Network Support 

 Service Center

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Page 1 GAO-14-175 VA Millennium Act Emergency Care

441 G St. N.W.

Washington, DC 20548

March 6, 2014

Congressional Requesters

The Veterans Millennium Health Care and Benefits Act (Millennium Act), 

enacted in 1999, provides a safety net for veterans who receive 

emergency care related to nonservice-connected conditions from nonDepartment of Veterans Affairs (VA) providers.1 Prior to the Millennium 

Act, VA only had the authority to pay for emergency care related to a 

veteran’s service-connected disability, and veterans with medical 

emergencies were reportedly trying to bypass local community hospitals 

to obtain care at VA facilities in order to avoid receiving medical bills.2

According to VA estimates, VA spent more than $418 million on 

Millennium Act emergency care claims in fiscal year 2012.3 VA projects 

that this spending will increase to $580 million by fiscal year 2015. 

Millennium Act coverage for veterans’ nonservice-connected emergency 

care services has a number of conditions, including that the veteran 

receiving the care be enrolled in VA’s health care system and have 

received treatment from a provider at a VA facility in the last 24 months; 

be financially liable for the care and have no coverage under another 

health plan, such as Medicare or a private health insurance plan; and that 

the claim be filed in a timely manner.4

 

1

Pub. L. No. 106-117, § 111, 113 Stat. 1545, 1553 (1999) (codified, as amended, at 

38 U.S.C. § 1725). Non-VA providers include hospitals and other health care providers, 

such as individual physicians and physicians’ groups.

In fiscal year 2012, more than 

8 million veterans were enrolled in VA health care, and VA Central Office 

estimated that about 23 percent of these veterans had no other health 

2

Emergency care related to a service-connected disability is payable under 38 U.S.C. 

§ 1728(a)(1)-(3). 

3

VA spent a total of $54 billion on veterans’ health care services in fiscal year 2012.

4

The claim must be filed within 90 days of the latest of the following: date of discharge; 

date of death, provided death occurred during transport to or stay in an emergency 

treatment facility; or date that the veteran exhausted actions, without success, to obtain 

payment or reimbursement from a third party. 38 C.F.R. § 17.1004(d).
 

Page 2 GAO-14-175 VA Millennium Act Emergency Care

insurance, making them potentially eligible for Millennium Act emergency 

care coverage.5

Since the enactment of the Millennium Act, concerns have been 

expressed about how VA medical facilities make decisions about 

coverage of emergency care for veterans from non-VA providers, 

including the denial of claims, and the extent to which VA educates 

veterans and non-VA providers about Millennium Act emergency care 

eligibility. You also asked us to review VA’s implementation of the 

Millennium Act and the effectiveness of VA policies related to informing 

veterans about how emergency care claims are reimbursed. This report 

examines the extent to which (1) selected VA facilities comply with 

applicable requirements when denying Millennium Act emergency care 

claims; (2) VA, through its oversight activities, ensures that Millennium 

Act emergency care claims are not inappropriately denied; and 

(3) veterans understand the Millennium Act emergency care benefit and 

how VA communicates with non-VA providers about Millennium Act 

emergency care claims.

To examine VA facilities’ compliance with applicable requirements when 

denying Millennium Act emergency care claims, we reviewed the 

Millennium Act and its implementing regulations, as well as VA policies 

and guidance related to processing Millennium Act emergency care 

claims.6 We also conducted site visits to four VA facilities selected on the 

basis of their Millennium Act spending levels for fiscal year 2012 and 

geographic variation, including whether they predominantly serve 

veterans from rural areas.7 Rurality is an important consideration for this 

study because veterans may have to travel long distances to reach a VA 

facility or a non-VA provider during an episode of emergency care.8

 

5

The estimate of the percentage of enrolled veterans with no other health insurance is 

weighted and based on responses from a representative sample of 42,000 veterans who 

were enrolled in VA health care as of September 30, 2011.

The 

6

The Millennium Act and its implementing regulations appear at 38 U.S.C. § 1725 and 

38 C.F.R. §§ 17.1000 – 17.1008, respectively.

7

For the purposes of this report, we considered VA facilities to be health care systems, 

which are typically made up of one or more VA medical centers, or stand-alone VA 

medical centers.

8

We included the Black Hills Health Care System and the White River Junction VA 

medical center in our sample because they serve veterans who live in rural or highly rural 

areas, according to VA’s Office of Rural Health.
 

Page 3 GAO-14-175 VA Millennium Act Emergency Care

four VA facilities represented a range of Millennium Act spending for fiscal 

year 2012. (See table 1.) We also reviewed documentation associated 

with 128 Millennium Act emergency care claims that were denied in fiscal 

year 2012, approximately 30 denied claims from each of the four VA 

facilities we visited. These denied claims were selected on the basis of 

variation in the total billed charges, diagnoses, veterans’ ages, and 

gender, and reflected the distribution of Millennium Act denial reasons 

recorded by the facility on all of the Millennium Act emergency care 

claims it denied in fiscal year 2012. In addition, we conducted interviews 

with officials from VA Central Office and the four VA facilities we visited.9

To assess the reliability of the Millennium Act spending data we used to 

select VA facilities and the claims data we used to select denied 

Millennium Act emergency care claims, we conducted interviews with 

knowledgeable agency officials, manually reviewed the content of the 

data, and electronically tested the data for missing values, outliers, and 

obvious errors. We found these data to be sufficiently reliable for 

selecting our samples of VA facilities and denied Millennium Act claims. 

Since these samples were not intended to be representative, our findings 

cannot be generalized to all VA facilities or all denied Millennium Act 

emergency care claims.

 

9

We interviewed VA Central Office officials from the Chief Business Office for Purchased 

Care, the office responsible for overseeing the National Non-VA Medical Care Program 

across the VA health care system. The Non-VA Medical Care Program was previously 

known within VA as the fee basis care program. For purposes of this report, we will use 

the term fee basis care to refer to non-VA medical care. Fee basis is the practice of paying 

for veterans’ health care services outside of VA when VA medical facilities are not feasibly 

available. This may include situations in which there is a lack of available VA specialists, 

there are long wait times for appointments, or there is an extraordinary distance between 

the VA facility and the veteran’s home. Millennium Act claims are a type of fee basis claim.
 

Page 4 GAO-14-175 VA Millennium Act Emergency Care

Table 1: Site Visit Locations

Source: VA data.

a

The North Texas VA Health Care System is made up of the Dallas and Bonham VA Medical Centers.

b

The Black Hills VA Health Care System is made up of the Hot Springs and Fort Meade VA Medical 

Centers.

To examine the extent to which VA ensures that Millennium Act 

emergency care claims are not inappropriately denied, we reviewed VA 

documents and interviewed officials from VA Central Office and the four 

VA facilities we visited. In addition, we assessed VA Central Office’s and 

VA facilities’ efforts to ensure that Millennium Act emergency care claims 

are not inappropriately denied in the context of federal standards for 

internal controls for (1) monitoring and (2) information and 

communications.10

To determine the extent to which veterans understand the Millennium Act 

emergency care benefit, we reviewed relevant VA documents and 

websites. We also interviewed (1) officials from VA Central Office; (2) VA 

facility officials responsible for (a) reviewing and paying Millennium Act 

emergency care claims, (b) assisting veterans with problems encountered 

while seeking care at the facility, and (c) enrolling and informing veterans 

about their health care benefits; and (3) representatives from three 

veterans service organizations.

The internal control for monitoring relates to an 

agency’s ability to provide reasonable assurance that deficiencies are 

detected and promptly resolved. The internal control for information and 

communications relates to an agency’s access to information needed to 

carry out its oversight responsibilities.

11

 

10See GAO, Standards for Internal Control in the Federal Government, 

In addition, we assessed VA Central 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).

11We interviewed VA Central Office officials from the Health Eligibility Center and the 

Chief Business Office for Purchased Care, and officials from the American Legion, 

Disabled American Veterans, and Veterans of Foreign Wars of the United States.

Total Millennium Act 

fiscal year 2012 spending 

(millions) VA facility (location)

$ 12.8 North Texas VA Health Care Systema (Texas)

$ 3.0 Washington DC VA Medical Center (Washington, DC)

$ 1.4 Black Hills VA Health Care Systemb (South Dakota)

$ 1.0 White River Junction VA Medical Center (Vermont)
 

Page 5 GAO-14-175 VA Millennium Act Emergency Care

Office’s and VA facilities’ efforts to evaluate gaps in veterans’ knowledge 

of the Millennium Act emergency care benefit in the context of federal 

standards for internal control for risk assessment. The internal control for 

risk assessment relates to the identification and analysis of relevant risks 

associated with achieving the agency’s stated objectives.12 For the four 

VA facilities we visited, we also reviewed veterans’ complaints related to 

VA eligibility issues that were entered in the Patient Advocate Tracking 

System in fiscal year 2012 and any Millennium Act-related appeals filed 

by veterans with the Board of Veterans’ Appeals from fiscal year 2010 

through the time of our site visits in 2013.13 To describe how VA 

communicates with non-VA providers about Millennium Act emergency 

care claims, in addition to VA Central Office and VA facility officials 

mentioned earlier, we also interviewed representatives of four non-VA 

providers that submitted Millennium Act claims for payment to the VA 

facilities we visited.14

 

12See 

In addition, we conducted a literature review of 

academic articles relating to veterans’ awareness of emergency care 

availability at non-VA providers and reviewed relevant VA resources 

available to non-VA providers, such as an electronic newsletter and 

website.

GAO/AIMD-00-21.3.1.

13Patient advocates are VA employees who are specifically designated at each facility to 

receive complaints from veterans and their representatives and work directly with 

management and employees to facilitate resolutions. Patient advocates are typically 

responsible for entering and tracking complaints and concerns in the Patient Advocate 

Tracking System. We analyzed data associated with the four issue codes relating to VA 

eligibility issues. Based in Washington, D.C., the Board of Veterans’ Appeals is composed 

of judges experienced in veterans’ law. The Board reviews benefit determinations made 

by local VA offices and issues decisions on appeals. Only two of the four facilities we 

visited had defended any appeals related to Millennium Act claims to the Board of 

Veterans’ Appeals from fiscal year 2010 through the time of our site visits in March and 

April 2013. We reviewed four appeals in total.

14We interviewed officials from a total of four non-VA providers: three hospitals with the 

highest volume of inpatient and outpatient Millennium Act emergency care claims denied 

in fiscal year 2012 by their associated VA facilities and one physicians’ group with the 

highest volume of inpatient and outpatient Millennium Act emergency care claims denied 

in fiscal year 2012 by its associated VA facility. We interviewed officials from non-VA 

hospitals that had submitted claims to the North Texas VA Health Care System, the Black 

Hills VA Health Care System, and the White River Junction VA Medical Center. The 

physicians’ group had submitted claims to the North Texas VA Health Care System. We 

contacted officials from two non-VA providers that had submitted claims to the 

Washington DC VA Medical Center, but they did not respond to our interview requests.
 

Page 6 GAO-14-175 VA Millennium Act Emergency Care

We conducted this performance audit from April 2013 to March 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Non-VA care services provided at non-VA facilities, referred to as fee 

basis services, are either

• emergent in nature and therefore would not have gone through the 

traditional VA preauthorization process, or

• preauthorized—that is, authorized in advance by VA; for example, by 

a referral for a consultation with a specialist from the veteran’s primary 

care provider.15

See table 2 for a description of the types of fee basis claims processed by 

VA.

 

15For more detail regarding the preauthorization process see GAO, VA Health Care: 

Management and Oversight of Fee Basis Care Need Improvement, GAO-13-441

(Washington, D.C.: May 31, 2013). Emergency care may become authorized if VA is 

notified within 72 hours of the episode of care that the veteran has sought care at a nonVA facility. Emergency care at a non-VA facility may also be authorized for veterans 

receiving medical services in a VA facility or nursing home up to the point that the veteran 

can be safely returned to the VA facility following the emergency care treatment at the 

non-VA facility.

Background

Types of Fee Basis Claims
 

Page 7 GAO-14-175 VA Millennium Act Emergency Care

Table 2: Types of Fee Basis Claims Processed by VA and Relevant Payment Authority

Type of claim Description and relevant payment authority

Emergency care Services without VA preauthorization (e.g., heart attack care, 

treatment of injuries from a motor vehicle crash)

Veterans Millennium Health Care and Benefits Act 

(emergency care for conditions not related to 

service-connected disabilities)

Services meeting criteria under 38 U.S.C. § 1725

Emergency care for conditions related to 

service-connected disabilities

Services meeting criteria under 38 U.S.C. § 1728

Preauthorizeda Services with prior VA authorization meeting criteria under 38 U.S.C. 

§ 1703 (e.g., cancer treatment, mammography)

Source: GAO analysis of VA policies.

a

In certain circumstances, emergency care provided by fee basis providers can be deemed 

preauthorized if the providers provide notification of a veteran’s admission within 72 hours.

Emergency care by fee basis providers may also be preauthorized for veterans receiving medical 

services in a VA facility or nursing home up to the point that the veteran can be safely returned to the 

VA facility following the emergency care treatment at the non-VA facility.

To process all fee basis claims, including Millennium Act claims, VA 

facilities use software called the Fee Basis Claims System (FBCS). FBCS 

is primarily a system that helps VA facilities administer payments to nonVA providers, as opposed to a system that automatically applies relevant 

criteria and determines whether claims are eligible for payment. As a 

result, VA relies on fee basis staff, such as administrative clerks and 

clinicians (typically nurses), to make decisions about which fee basis 

claims are eligible for payment and which payment authority applies to 

the claim. (See app. I for a flow chart describing how fee basis claims are 

processed, specifically Millennium Act claims.)

Non-VA providers submit claims, including Millennium Act claims, to VA 

facilities for processing and payment either in hard copy form or 

electronically. According to VA policy, hard copy claims must be datestamped upon receipt and scanned into FBCS. (See fig. 1.)

Fee Basis Claims Process
 

Page 8 GAO-14-175 VA Millennium Act Emergency Care

Figure 1: VA’s Process for Receiving Fee Basis Claims

Once a fee basis claim is received, fee basis staff are responsible for 

assigning the relevant payment authority and ensuring it has been routed 

to the correct VA facility. According to VA policy, fee basis staff should 

check FBCS to determine if the care was preauthorized or emergent to 

determine payment authority and proceed as follows (see fig. 2):

• If a claim was preauthorized, it should be assigned within FBCS as 

preauthorized.

• If the care was not preauthorized, the claim should be assumed to be 

emergent care. Fee basis staff should then check FBCS to determine 

if the veteran has a service-connected disability. If the emergent care 

was related to the veteran’s service-connected disability, the claim 

should be considered under 38 U.S.C. § 1728. If the emergent care 

was not related to a service-connected disability, the claim should be 

considered under the Millennium Act. Clinicians should make the final 

determination of whether the emergency care is related to the 

veteran’s service-connected disability.16

 

16If a claim is initially assigned for consideration under 38 U.S.C. § 1728 (emergency care 

related to a service-connected disability), but a clinician later determines that the claim is 

not for care related to the veteran’s service-connected disability, fee basis staff should 

reassign the claim for consideration under the Millennium Act.
 

Page 9 GAO-14-175 VA Millennium Act Emergency Care

Figure 2: VA’s Process for Determining Payment Authority and Verifying That Emergency Care Claims Were Routed to 

Correct VA Facility

a

The correct VA facility for considering a Veterans Millennium Health Care and Benefits Act 

(Millennium Act) claim is the facility of jurisdiction—the VA facility geographically located closest to 

the non-VA provider where the emergency care services were rendered. In cases where the non-VA 

provider is geographically located closest to a VA community-based outpatient clinic, the Millennium 

Act claim should be routed to the VA facility responsible for processing that clinic’s fee basis claims. 

The correct VA facility for considering an emergency care claim that is related to the veteran’s 

service-connected disability is the clinic of jurisdiction, which is the VA facility responsible for serving 

the county in which the non-VA provider that rendered the services is located.

After assigning an emergency care claim to the appropriate payment 

authority, fee basis staff should ensure that the claim has been routed to 

the correct VA facility, according to VA policy. The correct VA facility for 

considering a Millennium Act claim—that is, a claim for emergency care 

that is not related to a service-connected disability—is the VA facility 

geographically located closest to the non-VA provider where the 

emergency care services were rendered (called the facility of 

jurisdiction).17

 

17In cases where the non-VA provider is geographically located closest to a VA 

community-based outpatient clinic, the Millennium Act claim should be routed to the VA 

facility responsible for processing that outpatient clinic’s fee basis claims.

The correct VA facility for considering an emergency care 

claim that is related to the veteran’s service-connected disability is the VA 

facility responsible for serving the county in which the non-VA provider 

that rendered the services is located (called the clinic of jurisdiction). If the 

claim was routed to the incorrect VA facility, fee basis staff must forward 

the claim to the correct VA facility.
 

Page 10 GAO-14-175 VA Millennium Act Emergency Care

All of the following administrative and clinical criteria must be met in order 

for the services to be paid for by VA.

• Administrative criteria for payment of Millennium Act emergency care 

claims

• Claim is not payable under 38 U.S.C. § 1728 (emergency care for 

conditions related to service-connected disabilities).

• Claim is filed within 90 days of the latest of the following: the date 

of discharge; date of death, provided death occurred during 

transport to or stay in an emergency treatment facility; or date that 

the veteran exhausted, without success, action to obtain payment 

or reimbursement from a third party.

• Veteran is enrolled in the VA Health Care System and has 

received treatment from a VA clinician within 24 months of the 

emergency care episode.

• Veteran is financially liable to the non-VA provider of emergency 

care.

• Veteran has no entitlement to care under a health plan contract 

(such as Medicare or a private health insurance plan).18

• Veteran has no other contractual or legal recourse against a third 

party that would in whole extinguish his liability to the non-VA 

provider.19

• Clinical criteria for payment of Millennium Act emergency care claims

• Services were rendered in a hospital emergency department or a 

similar facility providing emergency care to the public.

 

18The 2010 amendments to the Millennium Act changed the definition of a health plan 

contract to exclude state laws requiring motor vehicle drivers to have auto insurance as a 

source of coverage. Act of Feb. 1, 2010, Pub. L. No. 111-137, §1(a)(2),123 Stat. 3495.

19The 2010 amendments to the Millennium Act also authorized VA to pay for treatment 

when a veteran has recourse against a third party for a portion, but not all, of the veteran’s 

liability. In such cases, VA becomes the secondary payer, such as when auto insurance 

only partly covers the veteran’s liability to the non-VA provider.

Millennium Act Emergency 

Care Criteria
 

Page 11 GAO-14-175 VA Millennium Act Emergency Care

• Services were rendered in a medical emergency as determined 

using the prudent layperson standard.20

• VA or other federal facility was not feasibly available to provide the 

needed care, and an attempt to use either would not have been 

considered reasonable by a prudent layperson.

• Services needed before veteran was stable enough to be 

transferred to a VA or other federal facility and before the VA or 

other federal facility agreed to accept the transfer. 

According to VA policy, fee basis staff must first apply the Millennium Act 

administrative criteria to determine if the claim warrants further clinical 

consideration. Fee basis staff responsible for reviewing Millennium Act 

criteria must gather information about a veteran and the episode of care 

from a variety of sources, such as FBCS, VA’s electronic medical record, 

and the non-VA provider, in order to make decisions about whether 

claims are eligible for payment.21 If a claim meets all administrative 

criteria, fee basis staff should route the claim to a clinician for review of 

the Millennium Act clinical criteria.

 

20A medical emergency exists when the condition is of such a nature that a prudent 

layperson would reasonably expect that delay in seeking immediate medical attention 

would be hazardous to life or health. The standard would be met if there was an 

emergency medical condition manifesting itself by acute symptoms of sufficient severity 

(including severe pain) that a prudent layperson who possesses an average knowledge of 

health and medicine could reasonably expect the absence of immediate medical attention 

to result in placing the health of the individual in serious jeopardy, serious impairment to 

bodily functions, or serious dysfunction of any bodily organ or part. See 38 C.F.R. 

§ 17.1002(b). The prudent layperson standard emphasizes the patient’s presenting 

symptoms, rather than the final diagnosis, when determining whether to pay emergency 

medical claims.

21If additional information is needed to process the claim, such as medical records from 

the non-VA provider relating to the episode of care, the fee basis staff who review 

Millennium Act administrative criteria are typically responsible for requesting this 

information from non-VA providers. Any additional information requested by VA must be 

submitted within 30 days of receipt of the request or VA will treat the claim as abandoned, 

that is, take no further action on the claim, unless, within the 30 day period, the claimant

requests additional time in writing.

Applying Millennium Act 

Administrative and Clinical 

Criteria
 

Page 12 GAO-14-175 VA Millennium Act Emergency Care

VA must provide written notice to the veteran and the claimant (usually, 

the non-VA provider) regarding the reason for the denial and inform them 

of their rights to request a reconsideration or to formally appeal the denial. 

If a veteran or non-VA provider has questions about a denied claim, 

claims should be reconsidered by a fee basis supervisor at the same 

facility. If the denial decision is upheld, the veteran or non-VA provider 

has the right to file an appeal through the Board of Veterans’ Appeals.

Our review of 128 denied Millennium Act claims from the four VA facilities 

we visited identified patterns of noncompliance with applicable 

requirements. As a result, some claims were inappropriately denied. In 

addition, we found that VA facilities may be failing to notify veterans that 

their Millennium Act emergency care claims have been denied. These 

findings suggest that veterans whose claims have been inappropriately 

denied may become financially liable for emergency care that VA should 

have covered, and they may not be aware of their rights to appeal these 

denials.

Among the 128 denied Millennium Act claims we reviewed, we found 66 

instances of noncompliance with applicable requirements that could be 

categorized into one of the following five areas: (1) not date-stamping and 

promptly scanning claims; (2) assigning claims to the incorrect payment 

authority; (3) not routing claims to the correct VA facilities; (4) incorrectly 

determining veterans’ enrollment and use of VA services; and (5) denying 

motor vehicle crash-related claims with insufficient documentation, which 

led some claims to be inappropriately denied. Some of the claims we 

reviewed exhibited more than one area of noncompliance. As a result of 

our review, the four VA facilities reconsidered and paid 25 of the 

Notifying Veterans and 

Non-VA Providers of 

Millennium Act Claim 

Denials

Selected VA Facilities 

Did Not Consistently 

Comply with 

Applicable 

Requirements for 

Processing Claims 

and Notifying 

Veterans When 

Denying Millennium 

Act Claims

Selected VA Facilities 

Erroneously Denied 

Millennium Act Claims 

Because of 

Noncompliance with 

Certain Applicable 

Requirements
 

Page 13 GAO-14-175 VA Millennium Act Emergency Care

Millennium Act claims we reviewed that had been inappropriately 

denied.22

The 128 Millennium Act claims we reviewed were rarely date-stamped by 

fee basis staff. Of the small percentage of claims we reviewed that had 

been date-stamped, almost all were submitted electronically and 

automatically received electronic date stamps when they were imported 

into FBCS. (See table 3.) VA policy requires facilities to date-stamp 

incoming claims so that fee basis staff can determine whether claims 

were submitted in a timely manner. Millennium Act claims must be 

received within 90 days of the latest of the following: the date of 

discharge; the date of the patient’s death, provided death occurred during 

transport to or stay in an emergency treatment facility; or the date that the 

veteran exhausted, without success, actions to obtain payment or 

reimbursement from a third party. VA can deny claims submitted after 

90 days.

Table 3: Hard Copy Millennium Act Claims Reviewed that Were Not Date-Stamped, at Four Selected VA Facilities

VA facility

Total number of 

denied Millennium 

Act claims reviewed

Total number of 

denied Millennium 

Act claims submitted 

by hard copy

Number of hard 

copy Millennium 

Act claims 

not date-stamped

Percentage of hard 

copy Millennium 

Act claims 

not date-stamped

Black Hills VA Health Care System 34 34 34 100%

North Texas VA Health Care System 32 22 22 100%

Washington DC VA Medical Center 30 27 24 89%

White River Junction VA Medical Center 32 27 27 100%

Source: GAO analysis of Millennium Act claims.

 

22Among the 128 claims we reviewed, there were instances of noncompliance with 

applicable requirements and, in some cases, insufficient documentation to substantiate 

the denial reasons indicated in FBCS. Thirty-four of the claims we reviewed had 

insufficient documentation to substantiate the denial reasons. The four VA facilities 

reconsidered a total of 42 claims that exhibited noncompliance or lacked documentation to 

substantiate reasons for denial, or otherwise raised doubts about whether they should 

have been denied. There are several reasons that VA facilities did not pay all 42 of these 

reconsidered Millennium Act claims. For example, in some cases, it was determined that 

the claims should have been denied for reasons other than those indicated in FBCS. In 

other cases, it was determined that duplicate versions of the claims had already been paid 

prior to our review.

Claims Were Not DateStamped and Not Scanned 

Promptly
 

Page 14 GAO-14-175 VA Millennium Act Emergency Care

We also found a significant percentage of hard copy Millennium Act 

claims with FBCS scan dates 30 or more days after the date the non-VA 

provider created the claims, raising questions about whether the claims 

were scanned promptly by VA staff when they were received.23

Table 4: Hard Copy Millennium Act Claims Reviewed with Scan Dates 30 Days or More after Creation Dates, at Four Selected 

VA Facilities

(See 

table 4.) VA policy requires facilities to scan incoming hard copy claims 

into FBCS upon receipt. Staff at three of the four VA facilities

acknowledged that they had sometimes experienced delays and backlogs 

in scanning incoming claims. For example, staff at one facility explained 

that they had inherited a backlog of unscanned fee basis claims when 

they began working in the fee office about 4 years ago, because their 

predecessors had reportedly ignored a large volume of claims and never 

scanned or processed them. Staff at another facility said that they 

experienced scanning delays because their scanning equipment was 

frequently broken.

VA facility

Number of hard copy 

Millennium Act claims with 

scan dates 30 or more days 

after claim creation date

Total number of hard 

copy Millennium Act 

claims reviewed

Percentage of denied 

Millennium Act claims with 

scan dates 30 days or more 

after claim creation date

Black Hills VA Health Care System 6 34 18%

North Texas VA Health Care System 7 22 32%

Washington DC VA Medical Center 11 27 41%

White River Junction VA Medical Center 10 27 37%

Source: GAO analysis of Millennium Act claims.

Note: Because these claims had scan dates that were 30 or more days after the dates the non-VA 

providers created the claims, it does not appear that the VA facilities scanned them on the date they 

were received.

None of the four VA facilities we visited had developed local policies or 

standard operating procedures to clearly communicate which staff at the 

facility are responsible for date-stamping and scanning incoming fee 

basis claims. Because the four VA facilities we visited had no local 

policies or standard operating procedures to delineate date-stamping and 

scanning responsibilities, and because fee basis staff at the four facilities 

 

23We compared the creation date on the claim form with the scan date on the FBCS claim 

history for each claim. In cases where more than 30 days had elapsed between the 

creation date and the scan date, we concluded that there had been a delay in scanning 

the claim.
 

Page 15 GAO-14-175 VA Millennium Act Emergency Care

were not following VA’s policies on date-stamping and scanning claims 

into FBCS, they may have inappropriately denied Millennium Act claims. 

When incoming claims are not date-stamped, staff reviewing the claims 

must use the scan date—which, in many cases, may be an incorrect 

record of when the claim was received—to determine whether non-VA 

providers submitted Millennium Act claims before the timely filing 

deadline.

At the four VA facilities we visited, we found a total of 15 claims that were 

considered and denied under the Millennium Act that should have been 

considered under a different payment authority, specifically, serviceconnected emergency care (6 claims) or preauthorized care (9 claims).

Only claims for emergency care not related to veterans’ serviceconnected disabilities should be considered for payment under the 

Millennium Act. However, we found the following:

• Claims for service-connected conditions incorrectly categorized. 

For six claims—including one from the Black Hills VA Health Care 

System, two from the North Texas VA Health Care System, two from 

the Washington DC VA Medical Center, and one from the White River 

Junction VA Medical Center—nonclinician fee basis staff denied 

payment after incorrectly categorizing claims that were related to 

veterans’ service-connected disabilities or failing to recognize that 

veterans had service-connected disabilities before they denied the 

claims under Millennium Act administrative or clinical criteria. This 

occurred because VA’s policy regarding determinations of whether 

emergency care claims are related to veterans’ service-connected 

disabilities is unclear. Currently, the policy does not specify that 

Millennium Act administrative and clinical criteria should be applied to 

claims only after a clinician has determined that the care was not 

related to any service-connected disability.

• Claims not categorized correctly as preauthorized care. For nine 

claims—including three from the Black Hills VA Health Care System, 

one from the Washington DC VA Medical Center, and five from the 

White River Junction VA Medical Center—fee basis staff denied 

payment because they did not recognize that these claims were for 

care that had been preauthorized by VA. This occurred because VA 

clinicians made non-VA care referrals but failed to follow VA’s policy 

of documenting the referrals in VA’s electronic medical record. As a 

result, fee basis staff were not alerted to create authorizations for the 

Claims Were Not Correctly 

Assigned for Millennium Act 

Consideration
 

Page 16 GAO-14-175 VA Millennium Act Emergency Care

referrals in FBCS.24

The 15 instances we identified where fee basis staff at the four VA 

facilities we visited made incorrect determinations about whether claims 

should have been considered for payment under the Millennium Act or 

another payment authority demonstrate that VA facilities are at risk for 

inappropriately denying veterans’ fee basis claims by applying the wrong 

payment criteria. These findings also raise concerns about the extent to 

which this may be occurring at other VA facilities nationwide.

In one case we reviewed, fee basis staff at that 

VA facility did not have access to any authorizations in FBCS that had 

been issued by other VA facilities and did not know, when the non-VA 

provider mistakenly submitted the claim to the nearest VA facility, that 

a VA clinician from a different VA facility had referred the veteran to 

the non-VA provider.

At two of the four VA facilities we visited, we found examples of denied 

Millennium Act claims that had not been routed to the correct VA facility. 

VA regulations specify that Millennium Act emergency care claims should 

be reviewed by the VA facility located nearest to where the non-VA 

provider rendered the services.25

For a total of six claims—three from the Washington DC VA Medical 

Center and three from the White River Junction VA Medical Center—we 

found that the claims were initially routed to the incorrect VA facility, 

which delayed their arrival at the correct VA facility. Two of these six 

claims were not date-stamped by the VA facility that initially received 

them and were then denied for not meeting the Millennium Act’s 90-day 

filing deadline after they reached the correct VA facility. Because the 

claims had not been date-stamped, fee office staff at the VA facilities we 

visited used the scan date recorded at their facility—which was not the 

 

24According to VA Central Office officials, VA has addressed this problem by creating a 

standardized process for clinicians to document referrals and alert fee basis offices of the 

need to create authorizations. VA has educated clinicians and fee basis staff about this 

standardized process and as of November 2013, VA Central Office officials said that the 

new process had been fully implemented at all VA facilities.

25VA Central Office officials said the reason Millennium Act claims should be routed to the 

VA facility nearest to where the non-VA provider rendered the services is that the nearest 

VA facility would be in the best position to address, for example, whether beds were 

feasibly available at the VA facility at the time the episode of care occurred and whether 

the VA facility would have been able to accept the transfer of the veteran from the non-VA 

provider.

Claims Were Not Routed to the 

Correct VA Facility for 

Consideration
 

Page 17 GAO-14-175 VA Millennium Act Emergency Care

date the claim was initially submitted to VA for consideration—to deny the 

claims for untimely filing.

In addition to the six, we found two claims that were processed and 

denied by the Washington DC VA Medical Center that should have been 

rerouted to other VA facilities. In one of those cases, the non-VA provider 

submitted the claim electronically, and VA’s claims system routed it to the 

incorrect VA facility. The claim was misrouted because electronic claims 

are automatically sent to the VA facility closest to the veteran’s 

residence—which may not be the correct VA facility to consider a 

Millennium Act claim, if the veteran received emergency care from a nonVA provider not located near his or her home. VA officials said the agency 

set up its electronic claims system to automatically route incoming claims 

to the VA facility closest to the veteran’s residence, because most fee 

basis claims are for preauthorized care, and it is most likely that the VA 

facility closest to the veteran’s residence was the facility that authorized 

the non-VA care. However, Millennium Act claims must be considered by 

the VA facility located nearest to where the non-VA provider rendered the 

services. While VA policy states this, it does not specify the point at which 

staff processing claims should verify that claims have been sent to the 

correct VA facility.

The instances we found at two of the four VA facilities we visited where 

claims were not routed to the correct VA facilities suggest that VA 

facilities are at risk for inappropriately denying Millennium Act claims. This 

also raises concerns about the extent to which other VA facilities 

nationwide may be inappropriately denying claims as well. If a claim is

delayed in reaching the correct VA facility—especially if it is not datestamped—the VA facility that processes the claim may not be able to 

make an appropriate determination about whether the claim met the 

Millennium Act’s 90-day filing deadline.

For six claims we examined—including three from the Washington DC VA 

Medical Center and three from the White River Junction VA Medical 

Center—we found that fee basis staff incorrectly determined that the 

veterans were not enrolled in the VA health care system or had not 

received VA care in the previous 24 months. VA policy for reviewing 

Millennium Act claims states that VA facilities should verify that a patient 

is not enrolled in the VA health care system or has not used VA health 

care within the 24 months prior to the episode of emergency care before 

denying Millennium Act claims. When examining these six claims, 

however, we found documentation showing that the patients were in fact 

Errors Were Made in 

Determining Veterans’ 

Enrollment and Use of VA 

Services
 

Page 18 GAO-14-175 VA Millennium Act Emergency Care

veterans who were enrolled or had used VA care within the 24 months 

prior to the episode of emergency care.

The reasons VA fee basis staff made these errors when denying these 

claims were not always clear.26

The instances where fee basis staff at two of the four VA facilities we 

visited made errors in determining veteran’s enrollment and use of VA 

services—because they relied on electronic search tools that provided 

incomplete information—indicate that the potential for VA facilities to 

inappropriately deny Millennium Act claims exists. This also raises 

concerns that staff at other VA facilities nationwide may have made 

similar errors. If fee basis staff at VA facilities do not consistently use the 

VSSC Find User search, they could continue to make incorrect 

determinations about veterans’ enrollment and use of VA services and 

inappropriately deny Millennium Act claims.

VA policy states that fee basis staff may 

choose from five different electronic search tools to make determinations 

about veterans’ enrollment and use of VA services. However, only one of 

those search tools—the Veterans Integrated Service Network Support 

Service Center (VSSC) Find User search—allows users to obtain 

information about veterans’ enrollment and use of VA services at any VA 

facility nationwide. In contrast, the other four electronic search tools 

provide information about enrollment and use of VA services only for 

veterans who are registered at the VA facility processing the claim.

At two of the four VA facilities we visited—the Black Hills VA Health Care 

System and the North Texas VA Health Care System—we found a total of 

two Millennium Act claims related to injuries sustained in motor vehicle 

crashes that had been denied because VA assumed the veterans had 

contractual or legal recourse against a third party, in this case, auto 

insurance.27

 

26Veterans are typically registered at the VA facility closest to their home. In three of the 

six claims, on the basis of the home address of the veterans, it appeared that the veterans 

were not registered at the VA facility that processed the claims, and the fee basis staff 

used electronic search tools that provided information about enrollment and use of VA 

services only for veterans who were registered at the facility where they worked. In the 

other three claims, there was no clear reason why the claims were denied, because the 

veterans were registered at the VA facility that processed the claims. The VA facilities did 

not provide reasons these claims were inappropriately denied.

However, VA fee basis staff at these facilities had no 

27In these cases, there was also no record that the veteran had other health insurance.

Medical Claims Related to 

Motor Vehicle Crashes Were 

Denied without Sufficient 

Documentation
 

Page 19 GAO-14-175 VA Millennium Act Emergency Care

documentation to support this and did not attempt to verify whether auto 

insurance covered the claims before denying them. In 2010 Congress 

amended the Millennium Act emergency care benefit to authorize VA to 

pay the balance of emergency medical claims when a third party is 

obligated to pay for only a portion of the care, such as when injuries 

sustained in motor vehicle crashes are not fully covered by auto 

insurance.28

The fee office manager at one of the facilities told us that the facility 

routinely denies emergency care claims related to injuries sustained in 

motor vehicle crashes because state law requires drivers to establish 

financial responsibility for their vehicles through auto insurance policies or 

other means, and the VA facility assumes that such claims related to 

motor vehicle crashes will be covered entirely by auto insurance. 

However, in that state, the law governing motor vehicle liability requires 

drivers to cover only injuries they cause to others as a result of crashes 

for which they are at fault. Fee basis staff cannot determine from a claim 

or medical records alone whether the veteran or another driver was at 

fault in the motor vehicle crash or whether the driver who was at fault had 

auto insurance coverage. Further, the law in that state only requires that 

auto insurance policies have a minimum of $30,000 in liability coverage 

for each injured person, up to a total of $60,000 per crash, but the 

average charge for the motor vehicle crash-related claims we reviewed 

from that facility was more than $69,000; therefore, the VA facility could 

still be responsible for paying the balance of some of the claims it denies 

without documentation of auto insurance coverage.

Therefore, before denying Millennium Act claims related to 

motor vehicle crashes, VA facilities should verify that (1) auto insurance 

or another third party covered the claim, and (2) there was no balance if 

auto insurance or another third party only partially covered the claim.

29

Officials from VA Central Office endorsed the practice of denying 

Millennium Act claims related to injuries sustained in motor vehicle 

crashes on the basis of third-party liability—without any documentation—

in states that have motor vehicle reparations laws. According to these 

 

28Act of Feb. 1, 2010, Pub. L. No. 111-137, 123 Stat. 3495 (2010).

29The average charge of $69,000 for the motor vehicle crash-related claims we reviewed 

at this facility is based on all claims we reviewed at that facility that were related to motor 

vehicle crashes, including the one claim we identified that had been denied because the 

VA facility assumed that the claim was covered by auto insurance, as well as the claims 

that had been denied for other reasons.
 

Page 20 GAO-14-175 VA Millennium Act Emergency Care

officials, it is the veteran’s responsibility to show that all possible avenues 

for payment have been exhausted before VA can pay a Millennium Act 

claim.

When we examined the standard letter that was sent to one of the 

veterans with a denied Millennium Act claim related to a motor vehicle 

crash, we found that it did not clearly state that the claim was denied 

under the assumption that auto insurance fully covered it, or that the 

denial could be overturned if the veteran proved that there was no auto 

insurance coverage for the crash or that auto insurance did not fully cover 

the medical claim.30

VA does not require its facilities to document that claims related to motor 

vehicle crashes were covered entirely by auto insurance before denying 

them, and VA does not require facilities to inform veterans that VA has

the authority to pay the balance of medical claims that are not fully 

covered by a third party. The instances we identified where two of the VA 

facilities we visited denied claims related to motor vehicle crashes under 

the assumption that they were covered entirely by auto insurance—

without any documentation of that coverage—suggest that staff at these 

VA facilities may be inappropriately denying payment for Millennium Act 

claims related to motor vehicle crashes. This also raises concerns that 

similar inappropriate denials may be occurring at other VA facilities 

nationwide.

(See app. II for a copy of this letter.)

VA policy states that VA must notify veterans in writing about denied 

claims and their appeal rights, but many of the Millennium Act claims we 

reviewed lacked documentation showing that the VA facility notified 

veterans that their claims had been denied. Table 5 shows the number of 

denied Millennium Act claims we reviewed at each VA facility for which 

VA lacked documentation of veteran notification. Claims lacked 

documentation of veteran notification when (1) the FBCS claim history did 

not indicate that a veteran denial letter was printed and the VA facility 

could not produce a copy of a veteran denial letter or (2) the FBCS claim 

history indicated that a veteran denial letter was printed but there were 

 

30In the other case where the VA facility denied a Millennium Act claim related to a motor 

vehicle crash under the assumption that the claim was covered by auto insurance, there 

was no evidence that the VA facility sent a letter to notify the veteran of the denial.

Selected VA Facilities Did 

Not Consistently Notify 

Veterans about Millennium 

Act Claim Denials and 

Their Appeal Rights
 

Page 21 GAO-14-175 VA Millennium Act Emergency Care

possible technological errors that resulted in no letter being printed 

because VA could not produce a copy of a veteran denial letter.

Table 5: Denied Millennium Act Claims Lacking Documentation that the Veteran Was Notified of Denial and Appeal Rights, at 

Four Selected VA Facilities 

VA facility

Number of denied 

Millennium Act claims 

lacking documentation 

veteran letter was printeda

(percentage of sample)

Number of denied Millennium 

Act claims with possible errors 

in printing lettersb

(percentage of sample)

Total number of denied 

Millennium Act 

claims reviewed

Black Hills VA Health Care System 2 (6%) 3 (9%) 34

North Texas VA Health Care System 15 (47%) 8 (25%) 32

Washington DC VA Medical Center 30 (100%) 0 (0%) 30

White River Junction VA Medical Center 4 (13%) 21 (66%) 32

Source: GAO analysis of Millennium Act claims.

a

The Fee Basis Claims System (FBCS) claim histories did not indicate that veteran letters were 

printed, and the VA facilities could not produce copies of any letters notifying the veterans of the 

denials and appeal rights.

b

The FBCS claim histories indicated that veteran letters were printed, but the VA facilities could not 

produce copies of the letters.

FBCS users must remember to periodically print veteran letters for denied 

Millennium Act claims because the system does not automatically print 

these letters, nor does it prompt users to print these letters after claims 

have been denied. Instead, veteran letters for denied claims collect in 

electronic queues organized by each non-VA provider, and FBCS users 

must periodically print the veteran denial letters that have collected in the 

queues.31

 

31The process for printing the letters has two steps. First, FBCS users must prompt FBCS 

to generate images of the letters, and then FBCS users must send the letters to a printer. 

According to VA Central Office officials, when users prompt FBCS to generate images of 

the veteran denial letters, notes are automatically added to the FBCS claim histories for 

those claims indicating that the veteran letter has been printed, whether or not the step of 

printing the letters is actually completed. After letters are printed, staff at VA facilities must 

place them in envelopes and mail them to the veterans. For the purposes of this report, 

we assumed that VA facilities mailed denial letters to veterans in cases where the FBCS 

claim history indicated that veteran letters were printed and the VA facilities were able to 

produce copies of the letters showing the date they had been printed. We had no means 

for confirming that the printed letters had actually been mailed or of verifying that veterans 

received the letters.
 

Page 22 GAO-14-175 VA Millennium Act Emergency Care

Officials from VA Central Office were unsure why some of the VA facilities 

we visited were unable to produce copies of veteran denial letters in all 

cases where the FBCS claim history indicated that a letter had been 

printed. These officials acknowledged that technological errors in FBCS 

can occur that could cause FBCS to fail to print veteran denial letters. For 

example, the officials explained that if there are too many letters waiting 

to be printed in FBCS, the system can become overloaded and fail to 

generate images and print the letters. In these cases, the FBCS claim 

history may still indicate that a letter was printed. VA Central Office 

officials said that such errors could occur when an FBCS user tries to 

print a large volume of veteran letters at one time.

The lack of documentation for many of the claims we reviewed at the four 

VA facilities we visited suggests that the four VA facilities we visited did 

not notify some veterans that their Millennium Act claims were denied and 

of their rights to appeal these denials. If similar situations are occurring at 

other VA facilities nationwide, where veterans are not informed of 

Millennium Act claim denials or of their appeal rights, and the claims have 

been inappropriately denied, then veterans could become financially 

liable for emergency care that VA should have covered.

Both VA Central Office and local VA facility oversight have weaknesses, 

and as a result, VA facilities are at risk for inappropriately denying 

Millennium Act claims. Oversight activities conducted by VA Central 

Office and VA facilities do not focus on compliance with applicable 

requirements, and VA cannot ensure that any deficiencies relating to 

Millennium Act claims processing identified during field assistance visits 

are corrected because VA conducts limited follow-up with VA facilities. 

Moreover, there is a lack of sufficient data for monitoring the 

appropriateness of Millennium Act claim denials.

VA Central Office’s and VA facilities’ efforts to oversee Millennium Act 

claims processing do not focus on the appropriateness of Millennium Act 

claim denials for the following reasons: (1) VA Central Office’s annual 

field assistance visits do not examine all practices at VA facilities that 

could lead claims to be inappropriately denied; (2) VA facilities do not 

systematically audit denied Millennium Act claims to ensure that they 

were denied appropriately; and (3) VA Central Office does not hold VA 

facilities accountable for correcting deficiencies it identifies during field 

assistance visits. According to the federal internal control standard for 

monitoring, agencies should assess the quality of performance over time 

VA Lacks Sufficient 

Oversight 

Mechanisms and 

Data to Ensure that 

VA Facilities Do Not 

Inappropriately Deny 

Millennium Act Claims

Oversight Does Not Focus 

on the Appropriateness of 

Millennium Act Claim 

Denials, and VA Central 

Office and VA Facilities 

Cannot Ensure that 

Deficiencies are Corrected
 

Page 23 GAO-14-175 VA Millennium Act Emergency Care

and provide reasonable assurance that deficiencies are detected and 

promptly resolved.32

According to VA Central Office, one of its primary methods for monitoring 

VA facilities’ processing of fee basis claims, including Millennium Act 

claims, is conducting field assistance visits. In fiscal year 2013, VA 

Central Office conducted field assistance visits at 30 VA facilities.33 Sites 

were selected for review and evaluated mainly on the basis of their 

timeliness in processing claims and less on the appropriateness of claim 

denials.34

On field assistance visits, VA Central Office uses a checklist to guide their 

observations of VA facilities’ fee basis claims processing, but the checklist 

does not examine all the practices we identified that could lead facilities to 

inappropriately deny Millennium Act claims.

For example, one of the VA facilities we visited was considered 

by VA Central Office to be one of the 10 best performing among its 

facilities because of its timeliness in processing claims, and therefore was 

not chosen for a field assistance visit in fiscal year 2013. However, our 

review of a sample of denied Millennium Act claims at this facility showed 

that fee basis staff were not complying with numerous policies for 

processing Millennium Act claims, which resulted in some claims being 

inappropriately denied and some veterans not being notified that their 

claims had been denied.

35

 

32See 

For example, while the 

checklist includes a step relating to whether fee basis claims are datestamped when they are received, it does not include steps for checking 

whether all fee basis staff who process Millennium Act claims consistently 

use the VSSC Find User search to determine if veterans are enrolled at 

GAO/AIMD-00-21.3.1.

33As of October 2012, there were 140 VA facilities that processed fee basis claims.

34VA Central Office selected the 30 lowest-performing facilities for field assistance visits 

based on the following measures: percentage of claim line items that are paid within 

30 days of receipt, percentage of claims that are processed (paid, denied, or rejected) 

within 30 days of receipt, and percentage of claims awaiting processing that were received 

fewer than 30 days ago.

35VA Central Office’s field assistance checklist for the fiscal year 2013 field assistance 

visits included 71 steps that related to the financial, clinical, administrative, and 

organizational functions of fee basis offices at VA facilities. The checklist applied to the 

processing of all fee basis claims, including Millennium Act claims, preauthorized claims, 

and claims for emergency care related to service-connected conditions.

Appropriateness of Millennium 

Act Claim Denials Is Not 

Addressed During Field 

Assistance Visits
 

Page 24 GAO-14-175 VA Millennium Act Emergency Care

other VA facilities and whether they have been seen by providers at other 

VA facilities in the last 24 months.

None of the fee basis managers at the four VA facilities said that they had 

put systematic procedures in place to audit samples of denied Millennium 

Act claims to ensure that staff complied with VA policies when they 

denied the claims and to ensure that Millennium Act claims are not 

inappropriately denied. VA Central Office officials said they have 

recommended but not required that fee basis managers at VA facilities 

audit samples of processed fee basis claims—including claims that have 

been approved for payment and claims that have been denied—to 

determine whether staff processed claims appropriately. However, VA 

Central Office does not know how many VA facilities conduct such audits. 

In addition, VA Central Office’s internal controls procedure guide for fee 

basis managers, which outlines the process by which fee managers are 

expected to help ensure compliance with VA policies, does not 

specifically communicate fee basis managers’ responsibilities for auditing 

the appropriateness of fee basis claim denials. Without systematic audits 

of the appropriateness of fee basis claims decisions, VA Central Office 

cannot adequately assess the performance of VA facilities in processing 

fee basis claims—including Millennium Act claims.

VA has implemented automated processes for auditing payments of 

approved fee basis claims—including Millennium Act claims—to ensure 

that VA facilities applied the correct payment rates and that no duplicate 

versions of the claims have already been paid. However, VA has no 

systemwide process for auditing the appropriateness of decisions made 

by fee basis staff to approve or deny fee basis claims.

One way that VA facilities could systematically audit the appropriateness 

of Millennium Act claim denials, in keeping with the federal internal control 

standard for monitoring, would be to include performance standards 

relating to the appropriateness of claims decisions in performance 

appraisal plans for fee basis staff. Such standards would help VA hold fee 

basis staff accountable for following VA policies and allow supervisors 

through these audits to identify staff that need additional training. At the 

time we visited the four VA facilities, none had implemented staff 

performance appraisal plans that included performance standards relating 

to the appropriateness of claims decisions. Three of the four facilities 

indicated that they planned to include such standards in future 

performance appraisal plans for fee basis staff, but only two of the VA 

facilities had draft performance appraisal plans at the time we visited. 

When we reviewed those two draft plans, we found that they included 

Appropriateness of Millennium 

Act Claim Denials Is Not 

Systematically Audited at 

Selected VA Facilities
 

Page 25 GAO-14-175 VA Millennium Act Emergency Care

performance standards relating to appropriateness of claims decisions, 

but neither of the draft plans specified whether the samples of fee basis 

claims reviewed would include both approved and denied claims, how the 

samples would be selected, or whether the samples would include certain 

percentages of Millennium Act claims and other types of fee basis claims.

Even though VA Central Office informs VA facilities of deficiencies that 

are identified during field assistance visits, and VA Central Office officials 

conduct some follow-up with the VA facilities to determine how the 

facilities address deficiencies, VA Central Office does not hold VA 

facilities accountable for correcting deficiencies identified through field 

assistance visits. When VA facilities respond with self-reported actions 

taken to address the deficiencies, VA Central Office has no process for 

validating facilities’ proposed actions. VA Central Office officials said that 

field assistance visits are meant to be consultative in nature to assist VA 

facilities in improving their fee basis claims processing.

Data we obtained on field assistance visits in fiscal years 2012 and 2013 

confirm VA’s current oversight weaknesses in this regard. In fiscal year 

2012, for example, one of the facilities VA visited was not making timely 

entries in FBCS of authorizations for referrals—a practice that, if not 

followed, could lead to the inappropriate denial of preauthorized fee basis

claims using inapplicable Millennium Act criteria, as we observed in our 

review of claims.36 VA Central Office observed this deficiency again in 

fiscal year 2013, even though the facility reported to VA Central Office 

that it had resolved the problems after the fiscal year 2012 field 

assistance visit. In another instance, we visited another VA facility 

approximately a year after its fiscal year 2012 field assistance visit and 

observed deficiencies that the facility and VA Central Office indicated had 

been fully resolved after the fiscal year 2012 field assistance visit. For 

example, one deficiency was related to the VA facility’s ability to promptly 

scan incoming fee basis claims—a practice that could lead to the 

inappropriate denial of Millennium Act claims, as we had observed in our 

review of claims—and the other deficiency was related to the VA facility’s 

failure to promptly notify veterans that their claims have been denied.37

 

36This is not one of the four VA facilities we visited for this study.

These findings raise concerns that VA facilities do not resolve identified 

deficiencies, as required by the federal internal control standard for 

37This VA facility was not selected for a field assistance visit in fiscal year 2013.

VA Facilities Are Not Held 

Accountable for Correcting 

Claims Processing 

Deficiencies Identified During 

Field Assistance Visits
 

Page 26 GAO-14-175 VA Millennium Act Emergency Care

monitoring, and VA Central Office may not be able to rely on facilities’ 

self-reported actions taken to correct deficiencies.

VA Central Office officials said they are planning to implement virtual 

audit teams, which, according to officials, would strengthen their oversight 

of fee basis claims processing. The officials said that VA facilities would 

be required to create action plans to address the findings of virtual audits, 

and facilities would be required to resolve deficiencies. However, VA 

Central Office’s written plan for the virtual audit teams indicates that they 

will only be auditing the appropriateness of claims decisions for claims 

that were paid, and it does not outline a process for independently 

validating facilities’ self-reported actions taken to correct deficiencies.

VA Central Office lacks sufficient data to monitor the appropriateness of 

Millennium Act claim denials because (1) VA has not required VA facilities 

to adhere to a uniform set of denial reasons in FBCS—thereby impeding 

a consistent evaluation across VA facilities—and (2) reports submitted to 

VA Central Office by the facilities mainly focus on timeliness, rather than 

whether the facilities correctly applied VA policies in denying claims.

In analyzing fiscal year 2012 Millennium Act claims that were denied by 

the four VA facilities we visited, we found no standardized, uniform set of 

Millennium Act denial reasons in FBCS. The lack of a standardized set of 

Millennium Act denial reasons in FBCS impedes VA Central Office’s 

ability to monitor VA facilities’ processing of these claims. According to 

the federal internal control standard for information and communications, 

agencies should ensure that management has access to the data it needs 

to carry out its oversight responsibilities.38

• track patterns in VA facilities’ Millennium Act claim denials,

Without a uniform set of 

Millennium Act denial reasons in FBCS, VA Central Office lacks data that 

would allow the agency to

• identify potential areas of noncompliance in VA facilities’ processing of 

Millennium Act claims, or

 

38See GAO/AIMD-00-21.3.1.

Sufficient Data Needed to 

Monitor Appropriateness 

of Denials of Millennium 

Act Claims Are Lacking
 

Page 27 GAO-14-175 VA Millennium Act Emergency Care

• identify areas where communications for veterans and non-VA 

providers about the Millennium Act emergency care benefit could be 

improved.

VA Central Office has not established a standardized list of denial 

reasons for VA facilities to use in FBCS; rather, VA Central Office allows 

VA facilities to create their own lists of Millennium Act denial reasons in 

FBCS.39

Moreover, in some cases, the FBCS denial reasons created by individual 

VA facilities are not aligned with Millennium Act administrative and clinical 

criteria and may not be valid reasons to deny Millennium Act claims. For 

example, at all four of the VA facilities, “not authorized” was a possible 

Millennium Act denial reason in FBCS. This denial reason lacks specificity 

and would not be a sufficient reason on its own to deny a Millennium Act 

claim, because Millennium Act claims are, by definition, claims for 

emergency care that was not preauthorized by VA. In order for a denial of 

a Millennium Act claim to be valid, the individual processing the claim 

would have to select an additional denial reason in FBCS that was 

aligned with one of the Millennium Act administrative or clinical criteria. 

However, in our review of claims from each of the four VA facilities we 

visited, we found examples of claims that were denied for “not 

authorized,” without any other valid Millennium Act denial reason.

While there are only 10 administrative and clinical criteria under 

which Millennium Act claims can be denied, each of the four VA facilities 

we visited had more than 10 denial reasons represented among the 

Millennium Act claims they denied in fiscal year 2012; in fact, one of the 

facilities had 75 different denial reasons.

At the four VA facilities, we also found multiple variations in the way 

denial reasons were expressed in FBCS for certain Millennium Act 

administrative and clinical criteria. For example, one facility had denial 

reasons of “veteran has other 3rd party insurance” and “veteran has other 

insurance,” and, according to the facility, both indicated that the veteran 

had access to coverage under another health plan. This data 

fragmentation makes it challenging for VA Central Office and the facilities 

to determine the most frequent or infrequent denial reasons for 

 

39VA Central Office officials said they submitted a request to the contractor responsible for 

making changes to FBCS to standardize the Millennium Act denial reasons about 4 years 

ago, but the contractor has yet to implement the enhancement because of competing 

priorities.
 

Page 28 GAO-14-175 VA Millennium Act Emergency Care

Millennium Act claims, compare patterns in Millennium Act claim denials 

within and across facilities, and identify potential areas where 

communications with veterans or non-VA providers could be improved. 

For example, without data indicating the reasons that Millennium Act 

claims are most frequently denied, VA Central Office and VA facilities are 

unable to target communications to better inform veterans and non-VA 

providers about the Millennium Act eligibility criteria related to those 

reasons.

VA Central Office’s oversight efforts are further impeded because the 

monthly reports officials rely on to monitor VA facilities’ performance in 

processing Millennium Act claims—called stoplight reports—focus on 

timeliness, rather than the appropriateness of VA facilities’ denial of such 

claims.40 For example, the only aspect of the monthly reports that relates 

to the appropriateness of claim denials is a tally of the instances in which 

veterans sought assistance from VA facilities with resolving adverse 

credit history reports resulting from unpaid fee basis claims. VA facilities 

are required to report the number of instances where the adverse impact 

to the veteran’s credit history was determined to be the fault of VA, such 

as cases where the VA facility did not process the fee basis claim in a 

timely manner. This measure may give VA Central Office some insight 

about the extent to which VA facilities processed fee basis claims 

inappropriately; however, since this measure is not specific to the type of 

fee basis claim, VA Central Office has no way to determine how many 

cases are related to Millennium Act claims. Because the facilities’ monthly 

reports lack robust data about the appropriateness of Millennium Act 

claims processing, VA Central Office is limited in its ability to carry out the 

oversight responsibilities described in the federal internal control standard 

for information and communications.

 

40These reports contain data relating to the quantity of fee basis claims processed, the 

timeliness of claims processing, and fee basis claims expenditures. The data in these 

reports relate to all types of fee basis claims VA facilities process, including Millennium Act 

claims, preauthorized claims, and emergency care claims related to service-connected 

conditions. 
 

Page 29 GAO-14-175 VA Millennium Act Emergency Care

VA employs a number of methods to educate veterans regarding their 

Millennium Act eligibility; however, VA officials, providers, and others we 

interviewed reported that most veterans with whom they interact have 

limited knowledge of their eligibility. Similarly, despite VA’s efforts, all four 

non-VA providers we interviewed cited problems in their communications 

with VA regarding Millennium Act emergency care claims processing.

Currently, according to VA officials, VA educates veterans regarding 

Millennium Act eligibility through patient orientation sessions, during 

which emergency care benefits are typically covered, and written 

materials, such as the VA Health Care Benefits Overview 2012, the 

Veterans Health Benefits Guide, and the Veteran Health Benefits 

Handbook.41

 

41In 2012, VA personalized the Veteran Health Benefits Handbook for veterans based on 

their priority group and eligibility, including eligibility guidelines for non-VA emergency 

care. According to VA, as of December 2013, the agency had mailed over 7.5 million 

personalized handbooks and continues to mail handbooks to all new enrollees. The 

Veteran Health Care Benefits Overview 2012 is available at VA facilities and online, while 

the Veteran Health Benefits Guide is only available online, and will be discontinued and 

replaced by a new Veteran Health Care Benefits Overview in the future. In addition, in 

some cases, VA facilities may produce their own pamphlets regarding the Millennium Act 

benefit and make them available within the facility.

Also, if veterans have specific questions about emergency 

care, they may also contact VA’s toll-free number for health care related 

questions (877-222-VETS), the patient advocate at a VA facility, the fee 

basis office at a VA facility, or veterans service organizations, according 

to VA officials. Finally, in response to requests made by veterans service 

organizations that were concerned about veterans’ lack of knowledge 

about VA emergency care eligibility, VA Central Office mailed a letter and 

a fact sheet in March 2013 to all enrolled veterans informing them of how 

emergency care from non-VA providers may be covered, according to VA 

Despite VA Efforts, 

Veterans Lack 

Knowledge about 

Millennium Act 

Eligibility, and 

Selected Non-VA 

Providers Report 

Communication 

Challenges with VA 

Regarding Millennium 

Act Claims

Veterans Often Have 

Limited Knowledge 

Regarding Millennium Act 

Eligibility
 

Page 30 GAO-14-175 VA Millennium Act Emergency Care

officials. This fact sheet is also available on VA Central Office’s National 

Non-VA Care Program website.

Despite VA’s efforts, VA officials from the four facilities we visited—

including benefits and enrollment officials, patient advocates, and fee 

basis officials—non-VA providers, and national representatives of 

veterans service organizations we interviewed commonly reported that 

most veterans with whom they had come into contact are not 

knowledgeable about the Millennium Act or the circumstances under 

which a Millennium Act emergency care claim can be paid.42

• A veteran may not understand what constitutes an emergency as 

defined by the Millennium Act and may expect that care at a non-VA 

provider for a condition he or she considers requires immediate 

attention will be covered regardless of whether it meets the prudent 

layperson standard for an emergency condition.

For 

example,

• A veteran who has been admitted to a non-VA hospital may not be 

aware that he or she should be transferred to a VA facility once 

stable. Under the Millennium Act, VA will reimburse the non-VA 

hospital only to the point at which the veteran is stable enough to be 

transferred.

• Veterans often are not aware of specific eligibility criteria and assume 

that VA will cover their non-VA emergency care automatically 

because they perceive it as an entitlement. For example, we reviewed 

one Millennium Act-related Board of Veterans’ Appeals case in which 

the veteran contended that he was entitled to VA payment for his nonVA emergency care, despite the fact that he did not meet the statutory 

eligibility requirements of having been seen at VA in the 24 months 

prior to his emergency episode of care and having no entitlement to 

care under a health plan contract.43

 

42A 2011 study of veterans at non-VA emergency departments also found that that some 

veterans may not be knowledgeable about their eligibility for VA health care coverage, 

including Millennium Act coverage. For example, the study found that 13 percent of 

veterans interviewed had no knowledge of their VA health care eligibility in general. S. M. 

Schneider, T. Richardson, W. Triner, et al., “Use of Non-Veteran Administration Medical 

Emergency Departments by Military Veterans.” Annals of Emergency Medicine, vol. 58, 

no. 4S (2011): 236.

Furthermore, he argued that he 

43As of December 2013, according to a facility official, the Board of Veterans’ Appeals had 

not yet made a final decision regarding this case.
 

Page 31 GAO-14-175 VA Millennium Act Emergency Care

should have been notified by VA that he needed to be seen every 

24 months to be eligible for Millennium Act coverage.

Furthermore, VA patient advocates and patient benefits and enrollment 

officials from the facilities we visited and representatives of a veterans 

service organization said that veterans typically seek information about 

VA’s coverage of emergency care received from non-VA providers after 

an episode of emergency care occurs, at which point the veteran has 

missed the opportunity to make more informed health care decisions.

Veterans’ lack of knowledge of Millennium Act eligibility criteria can have 

a potential negative impact on their ability to gain accessible and timely 

health care. VA officials we interviewed were aware of specific recent 

cases where veterans delayed or avoided seeking treatment at local nonVA providers to go to a VA facility instead.44

• two patient advocates we interviewed cited a case where the wife of a 

veteran who had gunshot wounds drove him to a VA facility about 

30 miles away, bypassing a number of other non-VA emergency 

departments,

For example,

• a VA Central Office official described an account involving a veteran 

experiencing chest pains who drove over 100 miles to a VA facility 

rather than going to the nearest emergency department, and

• another VA Central Office official cited a case where a veteran 

experiencing chest pains died during a weekend as he waited to seek 

care until the local VA community-based outpatient clinic opened on 

Monday.

Concerns about veterans’ access to care were expressed more broadly in 

a 2011 academic study of VA patients, providers, and staff at Midwestern 

VA primary care clinics. During the study, patients, providers, and staff all 

expressed concerns that veterans delay or avoid seeking emergency care 

at non-VA providers because they are not sure VA will cover their costs.45

 

44Representatives of veterans service organizations we interviewed were not aware of or 

did not report any recent cases where veterans delayed or avoided seeking treatment at 

local non-VA providers to go to a VA facility instead.

One VA patient interviewed as a part of the study reported that his wife 

45C. Buzza, S. S. Ono, C. Turvey, et al., “Distance is Relative: Unpacking a Principal 

Barrier in Rural Healthcare.” J Gen Intern Med, vol. 26, suppl. 2 (2011):648–54.
 

Page 32 GAO-14-175 VA Millennium Act Emergency Care

called VA while he was experiencing a heart attack, explaining that he 

had no insurance and they were not sure where to go. The couple was 

instructed to go to the nearest emergency room; however, VA later 

denied payment for the emergency care, and the couple was responsible 

for paying the associated costs. Another VA patient interviewed as part of 

the study, who lives 140 miles from the nearest VA medical center, cited 

the distance as a factor that had prevented him from seeking care during 

an emergency.

Given the outreach and education efforts VA has already put forward for 

veterans regarding Millennium Act eligibility requirements, we found no 

clear reasons why veterans still may be unaware of these requirements. 

Based on our discussions with officials from VA facilities and others, we 

did, however, identify several contributing factors. Following are 

examples.

• When we reviewed the March 2013 fact sheet covering Millennium 

Act benefits and eligibility that VA sent to enrolled veterans, we found 

that it did not list all the Millennium Act criteria. When we asked about 

this, VA Central Office officials said that the primary intent of the letter 

and fact sheet was to communicate the importance of promptly 

seeking care from the nearest emergency department and discourage 

veterans from delaying care or bypassing non-VA providers in the 

event of an emergency. The officials said that VA did not include all 

the Millennium Act criteria in the letter and fact sheet because they 

believed this might overwhelm veterans, raise veterans’ anxiety about 

whether VA will cover their care, and discourage them from seeking 

medical attention from non-VA providers in an emergency.

• VA patient benefits and enrollment officials with whom we spoke at 

two of the four facilities said that patient orientation sessions cover 

emergency care benefits for veterans; however, these sessions are 

generally not well-attended.

• Although one objective in VA’s fiscal year 2011-2015 strategic plan is 

to educate and empower veterans and their families through more 

outreach and more effective advocacy efforts, VA facility officials we 

interviewed reported that their facilities have not conducted any 

veteran evaluations to determine where gaps in information about 

health care benefits exist, including about Millennium Act eligibility, 
 

Page 33 GAO-14-175 VA Millennium Act Emergency Care

and VA Central Office does not require any facilities to do so.46

VA officials and national representatives of veterans service organizations 

we interviewed had some suggestions for improving veteran knowledge 

of Millennium Act emergency care coverage. For example, they 

suggested improving the clarity of Millennium Act eligibility criteria in 

written materials so veterans could more easily grasp the requirements 

and requiring veterans to attend orientation sessions upon enrollment.

As a 

result, VA is not fully aware of the gaps in veterans’ knowledge 

regarding Millennium Act eligibility. According to the federal internal 

control standard for risk assessment, agencies should identify risks 

that could impede the efficient and effective achievement of agency 

objectives. Without a complete understanding of veterans’ level of 

knowledge regarding their Millennium Act eligibility, especially given 

the risks for potentially negative effects on veterans’ health and 

finances as a result of lack of knowledge, VA’s potential for 

accomplishing its strategic objective of improving veteran outreach 

and advocacy is impeded.

Officials from four non-VA providers we interviewed cited instances of 

communications problems with VA about Millennium Act claims. Poor 

communication issues included the following:

• Point of contact at VA not designated. Two of the non-VA providers 

said they did not have a specific point of contact at their VA facilities 

who could answer concerns and issues about Millennium Act claims, 

leading to potential issues relating to resolving questions about 

Millennium Act claims in a timely manner.

• Delays in claims processing. Billing officials at one non-VA hospital 

said they often received no response after claims were sent to VA or 

experienced lengthy delays in the processing of their claims, in some 

cases, years. The officials said they had approached VA in 2008 to try 

to discuss ways to improve the claims process, but those efforts were 

unsuccessful.

 

46U.S. Department of Veteran Affairs, Strategic Plan Refresh Fiscal Year 2011-2015 

(Washington, D.C.: n.d.). This objective also includes improving the agency’s ability to 

listen to veterans and their families to learn more about what works best for them and 

establishing feedback mechanisms for continuous program and service improvement.

Selected Non-VA 

Providers Reported 

Communication 

Challenges with VA 

Regarding Claims
 

Page 34 GAO-14-175 VA Millennium Act Emergency Care

• Lack of responsiveness when attempting to transfer veterans. 

Officials at one non-VA hospital said they had experienced challenges 

in the past connecting with the inpatient admissions staff at their local 

VA facility, making it difficult for the non-VA hospital to transfer 

veterans to the VA facility after veterans were stabilized. According to 

these officials, the VA facility did not consistently answer calls during 

business hours or weekends.

• Failure to document discussions about potential transfers. An 

official from one non-VA hospital cited cases where the hospital had 

attempted to transfer stable veterans to the VA facility after an 

episode of emergency care, but the VA facility informed them that it 

was not able to accept the patient. Later, according to the non-VA 

hospital officials, the VA facility denied the claims because VA could 

find no record of any contact with the non-VA hospital regarding the 

potential transfers.

• Lack of electronic process for submitting medical records. Two 

of the non-VA providers said that not being able to send medical 

records electronically to VA presents a challenge in VA’s being able to 

process Millennium Act claims in a timely manner.47

At the field level, VA facilities communicate with non-VA providers in a 

number of different ways, according to VA facility officials we interviewed. 

For example, they have (1) informal, ad-hoc communications between VA 

fee basis office staff and non-VA providers regarding the status of 

Millennium Act claims; (2) telephone conversations between VA facility 

admissions staff and non-VA providers regarding the potential transfer of 

veterans being treated by non-VA providers; and (3) in some cases, 

targeted visits to selected non-VA providers to discuss claims processing 

or other billing issues.

For example, 

officials from one non-VA provider explained that the main VA facility 

with which it interacts prefers to receive claims electronically; yet, this 

facility has a difficult time receiving and scanning hard-copy medical 

records and matching them to the applicable electronic claim in a 

timely manner.

 

47One of the non-VA providers we interviewed had given its closest VA facility remote 

access to the hospital’s electronic medical records so that fee basis staff at the VA facility 

could more easily process fee basis claims, including Millennium Act claims. This was the 

only non-VA provider we interviewed that had established such an arrangement with the 

VA facility in its area.
 

Page 35 GAO-14-175 VA Millennium Act Emergency Care

At the national level, VA Central Office officials said that they have 

attempted to improve communications with non-VA providers in the last 

2 years. Specifically, VA Central Office communicates information to nonVA providers about Millennium Act emergency claims processing in a 

number of ways, including the following:

• the National Non-VA Care Program website, which provides 

resources and information about Millennium Act claims processing for 

non-VA providers;

• an electronic newsletter for non-VA providers, which provides updates 

and other information regarding fee basis claims processing; and,

• a 2012 letter mailed to all non-VA providers who billed VA in the last 

2 years, providing information about VA emergency care eligibility and 

references to the website and electronic newsletter for more 

resources.

On the basis of interviews we conducted with officials from four non-VA 

providers, however, some of VA Central Office’s attempts to improve 

communications regarding Millennium Act claims processing have not 

reached their intended audience. For example, none of the officials from 

the four non-VA providers recalled receiving the 2012 letter that VA 

Central Office sent to non-VA providers, and only two of the four 

providers were familiar with VA Central Office’s National Non-VA Care 

Program website; of the two non-VA providers, one commented that the 

information on the website was not useful because it did not contain the 

information the provider needed. None of the non-VA providers were 

aware of the electronic newsletter for non-VA providers, and VA Central 

Office officials acknowledged that a very small percentage of the non-VA 

providers who bill VA for fee basis care had signed up for the electronic 

newsletter.

In 2011, VA Central Office conducted a customer satisfaction survey for 

non-VA providers who had billed VA for any type of fee basis care. The 

findings of this survey, which had over 400 respondents, further support 

our finding that non-VA providers have experienced challenges 

communicating with VA.48

 

48The survey had a response rate of 10 percent.

There were significant percentages of 

unfavorable responses to the following customer service-oriented topics 

included in the survey:
 

Page 36 GAO-14-175 VA Millennium Act Emergency Care

• Access to VA staff for advice and assistance. More than half of all 

responses were unfavorable.

• Extent to which fee basis staff keep the non-VA provider 

informed of conditions and changes that affect them. Almost 

60 percent of all responses were unfavorable.

• Resolution of problems with minimal effort on the part of the 

non-VA provider. More than 80 percent of all responses were 

unfavorable.

• Extent to which problems are resolved quickly. Nearly 80 percent 

of all responses were unfavorable.

In addition to the establishment of the website and electronic newsletter 

noted earlier, according to VA officials, VA Central Office took some steps 

to improve its overall customer service and communications with non-VA 

providers after the 2011 survey, such as holding training sessions for VA 

facility fee basis managers on improving outreach with non-VA providers. 

VA Central Office recently completed a second round of the non-VA 

provider customer satisfaction survey in 2013, and saw some

improvement in their customer service measures, but overall, significant 

percentages of unfavorable responses persisted.49

Comments by two non-VA providers suggested that some local efforts by 

VA facilities had helped to improve claims processing and 

communications. For example, they reported that VA facilities’ claims 

processing and communications have been enhanced recently because 

of the consolidation of VA fee basis functions in one location and other 

efficiency efforts aimed at improving the exchange of information by two 

of the four VA facilities we visited.

According to VA, this 

survey of non-VA providers is one part of a broader effort, known as the 

Non VA-Care Coordination Initiative, which the agency is undertaking to 

improve the health care coordination of veterans who use health care 

within and outside the VA.

 

49For example, the customer service topic relating to the extent to which fee basis staff 

keep the non-VA provider informed of conditions and changes that affect them decreased 

by 13 percentage points, with 45 percent reporting unfavorable responses; the customer 

service topic relating to the extent to which problems are resolved quickly decreased by 

3 percentage points, with 74 percent reporting unfavorable responses. The survey had 

586 respondents and a response rate of 6 percent.
 

Page 37 GAO-14-175 VA Millennium Act Emergency Care

The Millennium Act provides critical safety net emergency care coverage 

for veterans when they do not have insurance and need emergency care 

that is not related to a service-connected disability. However, weaknesses 

in VA’s administration and oversight of this emergency care benefit have 

the potential to lead veterans to (1) by-pass the closest non-VA facility in 

an emergency because of confusion about eligibility and the fear of being 

held financially liable for expensive medical bills, and (2) financial harm. 

We identified weaknesses in three main areas that limit VA’s ability to 

effectively administer the emergency care provisions of the Millennium 

Act.

First, we found significant problems with processing Millennium Act 

emergency care claims at the four VA facilities we visited. Noncompliance 

by VA facility staff with applicable requirements to ensure that claims are 

reviewed correctly—such as date-stamping incoming claims and 

immediately scanning them into the FBCS, assigning claims to the correct 

payment authority and ensuring they are routed to the correct VA facility, 

and ensuring that staff use electronic search tools that provide complete 

information when staff make determinations about veteran eligibility and 

use of VA services—has resulted in some claims being inappropriately 

denied. Also, we are concerned by VA facilities’ practice of automatically 

denying emergency care claims related to motor vehicle crashes because 

fee basis staff have been instructed to assume that such claims will be 

covered entirely by auto insurance and by evidence that suggests 

veterans have often not been notified of their claim denials or rights to 

appeal. By not complying with applicable requirements for processing 

Millennium Act claims, inappropriately denying claims, and potentially not 

informing veterans of denials, VA facilities may make veterans financially 

liable for emergency care that VA should have covered. If these veterans 

were unable to pay these claims, their credit ratings may have been 

negatively affected and they may have faced personal financial 

hardships. Steps need to be taken to bring VA facilities into compliance 

with these requirements and prevent veterans from incurring unnecessary 

financial harm due to inappropriate denial of Millennium Act claims.

Second, we found that VA lacks sufficient oversight mechanisms and 

data to ensure that VA facilities do not inappropriately deny Millennium 

Act claims. The agency’s oversight activities do not focus on whether 

claims are denied appropriately and do not require facilities to correct 

identified deficiencies. Furthermore, VA does not have sufficient data to 

monitor the appropriateness of Millennium Act claim denials. As a result, 

VA Central Office has only a partial view of the Millennium Act claims 

processing picture. The claims we reviewed that were reconsidered and 

Conclusions
 

Page 38 GAO-14-175 VA Millennium Act Emergency Care

later paid would not have been identified through oversight mechanisms 

or data that VA currently has in place. Given these gaps in oversight, VA 

does not have the information it needs to ensure it is taking actions 

necessary to correct situations where facilities have erroneously denied 

Millennium Act claims.

Finally, we found that veterans generally have limited knowledge of their 

Millennium Act emergency care eligibility, and non-VA providers said they 

experience challenges in communicating with VA facilities about 

Millennium Act claims. Effective communication with veterans and 

between VA and non-VA providers is essential to the appropriate and 

successful reimbursement of Millennium Act emergency care claims. 

Veterans’ most detailed education about the Millennium Act emergency 

care benefit typically occurs after the episode of emergency care, at 

which point the veteran has missed the opportunity to make more 

informed health care decisions. VA facilities we visited do not conduct 

veteran evaluations to determine where gaps in information about health 

care benefits exist, including about Millennium Act eligibility, and VA 

Central Office does not require any facilities to do so, so VA’s ability to 

target efforts to educate veterans about the emergency care benefit is 

limited. Given reported instances of veterans bypassing local emergency 

departments to get to a VA facility and veterans seeking non-VA 

emergency care who assume it will be covered in situations in which it 

may not, it is critical that VA identify the gaps in veterans’ knowledge 

about the Millennium Act and better educate and inform veterans 

regarding their eligibility.

We recommend that the Secretary of Veterans Affairs direct the Under 

Secretary for Health to take the following 12 actions:

• To address VA facilities’ compliance with applicable requirements for 

processing non-VA provider emergency care claims,

• implement measures to ensure that all VA facilities comply with 

VA’s policy requirement that incoming claims be date-stamped 

and scanned into FBCS on the date of receipt.

• clarify policies and guidance for processing Millennium Act claims 

to specify that clinicians determine whether emergent care is 

related to a veteran’s service-connected disability before other 

Millennium Act criteria are applied to claims, and implement 

measures to ensure that all VA facilities comply with this policy.

Recommendations for 

Executive Action
 

Page 39 GAO-14-175 VA Millennium Act Emergency Care

• clarify the policy for processing Millennium Act claims to 

communicate the importance of promptly verifying that claims 

have been sent to the correct VA facility, and implement measures 

to ensure that all VA facilities comply with this policy. 

• revise VA policy for processing Millennium Act claims to require 

that VA fee basis staff who process the claims use the VSSC Find 

User search to make determinations about veterans’ enrollment 

and use of VA services.

• establish a VA policy regarding processing Millennium Act claims 

to require VA facilities to assist the veteran in determining whether 

a claim is eligible for coverage by auto insurance or another third 

party before denying the claim; and ensure that the standard 

letters sent to veterans whose claims are denied because of thirdparty liability, in this case auto insurance coverage, more clearly 

communicate that the denial could be overturned if the veteran 

can prove that auto insurance did not fully cover the claim.

• To better ensure that veterans are notified of Millennium Act 

emergency care claim denials, require fee basis supervisors at each 

VA facility to develop mechanisms for verifying that veteran denial 

letters are printed and mailed.

• To improve oversight of Millennium Act claims processing by 

increasing the focus on determining whether claims are 

inappropriately denied and ensuring that deficiencies are corrected,

• revise the scope of field assistance visits to include an 

assessment of whether fee basis staff are making appropriate 

decisions about whether Millennium Act claims meet 

administrative and clinical criteria for payment.

• require VA facilities to systematically audit the appropriateness of 

Millennium Act claim approvals and denials by taking actions such 

as revising VA Central Office’s internal controls procedure guide 

for fee basis managers or by establishing performance measures 

related to the appropriateness of claim approval or denial 

decisions for fee basis staff.

• require VA facilities to correct fee basis claims processing 

deficiencies that are identified through field assistance visits or 

virtual audits, once they are implemented, and establish a process 

for validating facilities’ self-reported actions taken to address 

deficiencies.
 

Page 40 GAO-14-175 VA Millennium Act Emergency Care

• To improve VA’s ability to identify systemwide patterns in denials, 

areas of noncompliance in VA facilities’ processing of Millennium Act 

claims, and areas where communications for veterans and non-VA 

providers could be improved,

• establish a standard set of Millennium Act denial reasons in FBCS 

that are specific and aligned with the Millennium Act administrative 

and clinical criteria, and ensure they are consistently applied 

across VA facilities.

• establish a regular reporting mechanism through which VA 

facilities would provide to VA Central Office data related to the 

appropriateness of decisions to approve or deny Millennium Act 

claims.

• To improve VA’s ability to address its strategic plan objective of 

educating and empowering veterans, take steps to better understand 

gaps in veterans’ knowledge regarding eligibility for Millennium Act 

emergency care, such as by conducting veteran surveys of health 

care benefits knowledge, and using information from those surveys to 

more effectively tailor the agency’s education efforts regarding the 

Millennium Act benefit. In conducting these surveys, consideration 

should be given to including a sample of veterans who have had 

denied Millennium Act claims in order to provide their views and 

specific details of their experiences.

VA provided written comments on a draft of this report, which we have 

reprinted in appendix III. In its comments, VA generally agreed with our 

conclusions, concurred with our 12 recommendations, and described the 

agency’s plans to implement each of our recommendations. VA also 

provided technical comments, which we have incorporated as 

appropriate.

While the draft report was at VA for comment, we had discussions with 

officials from VA’s Chief Business Office for Purchased Care about 5 of 

the 12 recommendations in the draft report. As a result of these 

discussions, we have made revisions to five recommendations in this 

report as described below.

• Three recommendations in the draft report involved VA facilities 

developing local standard operating procedures to communicate to 

staff how they should comply with three requirements related to 

processing Millennium Act emergency care claims: 

(1) promptly date-stamping and scanning incoming claims, 

Agency Comments

and Our Evaluation
 

Page 41 GAO-14-175 VA Millennium Act Emergency Care

(2) determining whether emergent care is related to a veteran’s 

service-connected disability before applying Millennium Act criteria, 

and (3) verifying that Millennium Act claims have been sent to the 

correct VA facility for processing. VA officials told us that while they 

agreed that the agency needs to implement measures to ensure that 

all VA facilities comply with these three requirements, they did not 

believe that requiring VA facilities to develop local standard operating 

procedures was the best way to achieve compliance. After these 

discussions, we decided to remove the establishment of local 

standard operating procedures at VA facilities from the three 

recommendations and to instead provide VA the flexibility to 

implement nationwide measures to ensure that VA facilities comply 

with requirements for processing Millennium Act claims. 

• One recommendation in the draft report involved an enhancement to 

FBCS that would prompt users to print veteran letters as claims are 

approved or denied. VA officials explained that they would face 

challenges in implementing a technological enhancement for FBCS, 

so we removed this aspect of our recommendation and instead are 

recommending that VA require fee basis supervisors at each VA 

facility to develop mechanisms for verifying that veteran denial letters 

are printed and mailed. 

• The fifth recommendation in our draft report that we discussed with 

VA officials involved VA facilities reporting to VA Central Office data 

related to the appropriateness of Millennium Act claim decisions 

through their monthly stoplight reports. VA officials explained that 

while they agreed with the intent of the recommendation—that VA 

facilities regularly report data related to the appropriateness of 

decisions to approve or deny Millennium Act claims—they preferred 

not to use the stoplight report as the mechanism for collecting these 

data from VA facilities. We have revised the recommendation to 

provide VA more flexibility in determining the best mechanism for 

collecting data from VA facilities on the appropriateness of decisions 

to approve or deny Millennium Act claims. 

Our review of VA’s proposed actions to implement the 12 

recommendations in this report indicates that these actions are only likely 

to address 5 of the recommendations, partially address the issues raised 

in 3 of the recommendations, and not likely to adequately address 4 of 

the recommendations, as summarized below.

Specifically, we believe that VA’s plans, when implemented, would 

address the following five recommendations.
 

Page 42 GAO-14-175 VA Millennium Act Emergency Care

• VA stated that to address our first recommendation—to promptly datestamp and scan incoming claims—it plans to communicate the 

importance of adherence to these policy requirements through 

biweekly publications and through teleconferences for fee basis staff. 

VA also plans to update the checklist used on its field assistance visits 

and to develop national training to help ensure compliance with these 

requirements.

• To address our fifth recommendation, concerning denials of claims 

related to motor vehicle crashes, VA plans to examine VA facilities’ 

current processes to identify best practices for handling claims related 

to motor vehicle crashes, consider possible revisions to current policy, 

and assess the feasibility of modifying the standard letter sent to 

veterans whose claims are denied because of auto insurance 

coverage. VA also plans to develop national training to help ensure 

compliance with requirements for processing Millennium Act claims 

related to motor vehicle crashes.

• To address our ninth recommendation—to require VA facilities to 

correct fee basis claims processing deficiencies that are identified 

through field assistance visits or virtual audits by establishing 

procedures for reporting noncompliant VA facilities to VA Central 

Office leadership for further action—VA stated that the Chief Business 

Office for Purchased Care will establish procedures for identifying and 

reporting noncompliant sites.

• To address our 10th recommendation—to establish a standard set of 

Millennium Act denial reasons in FBCS that are specific and 

consistently applied across VA facilities—VA stated that it had 

previously submitted a request to the VA Office of Information and 

Technology for an FBCS enhancement, but it was not funded. 

Instead, VA plans to update its policy, if necessary, and assess the 

feasibility of locking down a uniform set of denial reasons in FBCS to 

prevent users at VA facilities from making changes.

• To address our 12th recommendation—to take steps to better 

understand gaps in veterans’ knowledge regarding their eligibility for 

the Millennium Act emergency care benefit—VA stated that it plans to 

identify options for surveying veterans, explore the possibility of 

promoting veteran education through conferences or town hall 

meetings organized by veterans service organizations, and review 

information currently available on VA’s websites and update it if 

necessary.
 

Page 43 GAO-14-175 VA Millennium Act Emergency Care

We believe that VA’s plans to address 3 of our 12 recommendations will 

only partially address some of the areas of noncompliance we identified 

during our review. Specifically, 

• in response to our second recommendation—that VA clarify policies 

to specify that clinicians determine whether emergent care is related 

to a veteran’s service-connected disability before any Millennium Act 

administrative or clinical criteria are applied to claims—VA did not 

indicate that it planned to review or update its policy. VA’s current 

policy does not specify that Millennium Act criteria should be applied 

to claims only after a clinician has determined that the care was not 

related to any service-connected disability. In our review of 128 

denied Millennium Act claims, we identified claims that were 

considered and denied under the Millennium Act that should have 

been considered and potentially could have been paid under different 

payment authorities. We believe that if VA does not clarify its policies, 

VA facilities will remain at risk for inappropriately denying claims.

• in response to our third recommendation—that VA clarify its policy to 

communicate the importance of promptly verifying that Millennium Act 

claims have been sent to the correct VA facility—VA stated that it 

would review and update policy if necessary. When we reviewed this 

policy, we determined that it does not specify the point in the 

Millennium Act claim review process at which staff processing the 

claims should verify that they have been sent to the correct facility, 

and our review of 128 denied Millennium Act claims revealed 

examples of denied claims that had not been routed to the correct VA 

facility. If claims are not routed to the correct VA facility in a timely 

manner, especially if they have not been date-stamped by the facility 

that initially received them, they could be inappropriately denied for 

not meeting the Millennium Act’s 90-day filing deadline. We continue 

to believe a clarification of VA’s policy could help to address this 

issue.

• to address our sixth recommendation, regarding veteran notification of 

claim denial, VA stated that it plans to assess the feasibility of 

enhancing FBCS to allow notations and dates to be added to claim 

histories to document when notifications of denial have been printed 

for non-VA providers and veterans. It is our understanding that FBCS 

already has the capacity to document the date that these notifications 

were printed, but our review of 128 denied Millennium Act claims 

revealed possible errors in printing these notifications because the VA 

facilities we visited could not produce copies of veteran denial letters 

in all cases where the FBCS claim histories indicated that letters had 
 

Page 44 GAO-14-175 VA Millennium Act Emergency Care

been printed. In light of this technological error, we believe a revision 

of VA’s policies for processing Millennium Act claims to require fee 

basis supervisors at each VA facility to develop a mechanism to 

ensure that veteran denial letters are printed and mailed would 

provide assurance of notification until a technological solution is 

instituted.

VA’s planned actions on the remaining four recommendations do not, in 

our opinion, adequately address our concerns and will not be sufficient to 

correct program weaknesses. Specifically,

• in response to our fourth recommendation—that VA revise its policy to 

require fee basis staff to use the VSSC Find User search to make 

determinations about veterans’ enrollment and use of VA services—

VA stated that it would review current policy and update it if 

necessary. We appreciate VA’s commitment to examining this policy, 

but our review of VA policies and 128 denied Millennium Act claims 

from four VA facilities revealed that weaknesses in this policy exist, 

and VA facilities are at risk for inappropriately denying Millennium Act 

claims. Specifically, we found that current VA policy permits fee basis 

staff to use electronic search tools that provide incomplete information 

about veterans’ enrollment and use of VA services when they are 

making determinations about whether claims meet the Millennium Act 

criteria. We believe that if VA does not revise its policies to clarify for 

fee basis staff the correct way to process Millennium Act claims, VA 

facilities will remain at risk for inappropriately denying claims.

• to address our seventh recommendation—to revise the scope of field 

assistance visits to include an assessment of whether fee basis staff 

are making appropriate decisions about whether Millennium Act 

claims meet administrative and clinical criteria for payment—VA 

indicated that it plans to incorporate additional interview questions in 

its field assistance visit checklist. While this is a positive step, we 

believe that the goal of ensuring compliance with applicable 

requirements would be better achieved by reviewing samples of 

approved and denied Millennium Act claims, rather than interviewing 

staff about Millennium Act requirements during field assistance visits, 

because our interviews with fee basis staff at four VA facilities did not 

reveal the types of noncompliance we found during our review of 

denied claims.
 

Page 45 GAO-14-175 VA Millennium Act Emergency Care

• to address our eighth recommendation—to require VA facilities to 

systematically audit the appropriateness of Millennium Act claim 

approvals and denials—VA stated that it has already established a 

virtual audit process to check paid claims for improper payments. VA’s 

effort to ensure that Millennium Act payment rates are correct is an 

important goal, but this action does not address our finding that VA 

facilities were making incorrect determinations about whether 

Millennium Act claims met the criteria for payment. VA also stated in 

its comments on this recommendation that it plans to review its 

internal controls procedure guide for fee basis managers and update it 

if necessary. When we reviewed this procedure guide, we found that it 

does not specifically communicate fee basis managers’ 

responsibilities for auditing the appropriateness of fee basis claims 

decisions; thus, we continue to believe that an update is necessary. 

• to address our 11th recommendation—to establish a regular reporting 

mechanism through which VA facilities would provide to VA Central 

Office data related to the appropriateness of decisions to approve or 

deny Millennium Act claims—VA stated that it would assess the 

feasibility of tracking and reporting VA facilities’ denial and approval 

reasons for Millennium Act claims. We do not believe that this planned 

action is responsive to our recommendation, which is intended to 

improve VA’s ability to monitor the performance of its facilities and 

provide insight about the extent to which VA facilities have made 

incorrect determinations about whether Millennium Act claims met the 

criteria for payment. As a result, we continue to believe that a 

requirement that VA facilities regularly report data related to the 

appropriateness of Millennium Act claim decisions is necessary to

help VA carry out its oversight responsibilities.

We are sending copies of this report to the Secretary of Veterans Affairs, 

appropriate congressional committees, and other interested parties. In 

addition, the report is available at no charge on the GAO Web site at 

http://www.gao.gov. 
 

Page 46 GAO-14-175 VA Millennium Act Emergency Care

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or williamsonr@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs are on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix IV. 

Randall B. Williamson

Director, Health Care
Page 47 GAO-14-175 VA Millennium Act Emergency Care

List of Requesters

The Honorable Jeff Miller

Chairman

Committee on Veterans’ Affairs

House of Representatives

The Honorable Karen Bass

House of Representatives

The Honorable Ken Calvert

House of Representatives

The Honorable John Campbell

House of Representatives

The Honorable Lois Capps

House of Representatives

The Honorable Judy Chu

House of Representatives

The Honorable Jim Costa

House of Representatives

The Honorable Susan Davis

House of Representatives

The Honorable Joe Heck

House of Representatives

The Honorable Duncan Hunter 

House of Representatives

The Honorable Darrell Issa

House of Representatives

The Honorable Kevin McCarthy

House of Representatives

The Honorable Howard P. “Buck” McKeon

House of Representatives
Page 48 GAO-14-175 VA Millennium Act Emergency Care

The Honorable Gary Miller

House of Representatives

The Honorable Grace Napolitano

House of Representatives

The Honorable Dana Rohrabacher

House of Representatives

The Honorable Lucille Roybal-Allard

House of Representatives

The Honorable Ed Royce

House of Representatives

The Honorable Loretta Sanchez

House of Representatives

The Honorable Adam Schiff

House of Representatives

The Honorable Brad Sherman

House of Representatives

The Honorable Henry A. Waxman

House of Representatives
Appendix I: VA’s Process for Receiving Fee 

Basis Claims and Processing Millennium Act 

Claims

Page 49 GAO-14-175 VA Millennium Act Emergency Care

a

The correct VA facility for considering a Millennium Act claim is the facility of jurisdiction—the VA 

facility geographically located closest to the non-VA provider where the emergency care services 

were rendered. In cases where the non-VA provider is geographically located closest to a VA 

community-based outpatient clinic, the Millennium Act claim should be routed to the VA facility 

responsible for processing that clinic’s fee basis claims.

Appendix I: VA’s Process for Receiving Fee 

Basis Claims and Processing Millennium Act 

Claims
Appendix II: Example of a Standard Veteran 

Denial Letter for a Claim Related to a Motor 

Vehicle Crash

Page 50 GAO-14-175 VA Millennium Act Emergency Care

Note: To protect the veteran’s privacy, any potentially identifying information was redacted.

Appendix II: Example of a Standard Veteran 

Denial Letter for a Claim Related to a Motor 

Vehicle Crash
Appendix III: Comments from the Department 

of Veterans Affairs

Page 51 GAO-14-175 VA Millennium Act Emergency Care

Appendix III: Comments from the 

Department of Veterans Affairs
Appendix III: Comments from the Department 

of Veterans Affairs

Page 52 GAO-14-175 VA Millennium Act Emergency Care
Appendix III: Comments from the Department 

of Veterans Affairs

Page 53 GAO-14-175 VA Millennium Act Emergency Care
Appendix III: Comments from the Department 

of Veterans Affairs

Page 54 GAO-14-175 VA Millennium Act Emergency Care
Appendix III: Comments from the Department 

of Veterans Affairs

Page 55 GAO-14-175 VA Millennium Act Emergency Care
Appendix III: Comments from the Department 

of Veterans Affairs

Page 56 GAO-14-175 VA Millennium Act Emergency Care
Appendix III: Comments from the Department 

of Veterans Affairs

Page 57 GAO-14-175 VA Millennium Act Emergency Care
Appendix III: Comments from the Department 

of Veterans Affairs

Page 58 GAO-14-175 VA Millennium Act Emergency Care
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 59 GAO-14-175 VA Millennium Act Emergency Care

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Marcia A. Mann, Assistant 

Director; Stella Chiang; Daniel K. Lee; Alexis C. MacDonald; 

Elizabeth T. Morrison; Lisa Motley; and Jennifer Whitworth were 

major contributors to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments
Related GAO Products

Page 60 GAO-14-175 VA Millennium Act Emergency Care

VA Health Care: Additional Steps Needed to Strengthen Beneficiary 

Travel Program Management and Oversight. GAO-13-632. Washington, 

D.C.: July 15, 2013.

VA Health Care: Management and Oversight of Fee Basis Care Need 

Improvement. GAO-13-441. Washington, D.C.: May 31, 2013.

Related GAO Products

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